Medicaid audit contractors lag behind Medicare counterparts, federal officials admit

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Long-term care makes ADP's list of industries most challenged by upcoming health benefits requiremen
Long-term care makes ADP's list of industries most challenged by upcoming health benefits requiremen

Federal officials acknowledged in a House hearing Thursday that Medicaid's recovery contractors have not been as successful as their Medicare counterparts in detecting fraud and recovering overpayments.

Variations between state Medicaid programs have resulted in a big learning curve for recovery auditors, Centers for Medicare & Medicaid Services officials told the House Subcommittee on Government Organization, Efficiency, and Financial Management Thursday. Auditors have faced significant challenges in accurately applying the policies unique to each state, CMS official Ann Maxwell, regional inspector general for evaluation and inspections, said.

“These problems led Medicaid Integrity Contractors to misidentify potential overpayments and the Medi-Medi [Medicare-Medicaid] program to identify fewer overpayments and fewer cases of potential fraud for Medicaid than it did for Medicare,” Maxwell told the panel.

CMS officials also responded to criticism from Rep. James Lankford (R-OK) that providers view Medicare recovery audits as “hostile events,” comparing auditors to “bounty hunters.” He also noted that providers are shelling out tens to hundreds of thousands of dollars responding to the RAC audits. Peter Budetti, deputy CMS administrator for program integrity, told committee members that it is listening to provider concerns and discussing these matters internally.

Long-term care payment experts have been vocal in warning nursing homes to be fully prepared for the “surveyor mentality” from Medicare auditors.

Click here to listen to the testimony.

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