Skilled care operators receive more money from Medicaid than any other public or private funding source. Federal officials Tuesday announced plans to rein in program spending via stepped up anti-fraud efforts.
Specifically, regulators want more aggressive auditing, enhanced oversight of state contracts with private insurers, scrutinizing program eligibility more closely and stricter rules enforcement.
Spending on the low-income healthcare payment program — borne by both states and the federal government — has ballooned in recent years, fueled partly by Medicaid expansion, the Centers for Medicare and Medicaid Services noted in its announcement. Federal funding for the program jumped from $263 billion in 2013 to $363 billion in 2016.
“As we give states the flexibility they need to make Medicaid work best in their communities, integrity and oversight must be at the forefront of our role,” CMS Administrator Seema Verma said in a statement. CMS specifically cited three new initiatives that will be tied to enhanced rules enforcement:
(1) Medical loss ratio audits: CMS will start auditing some states tied to the amount they spend on clinical services and quality improvement, weighed against what’s allotted for administration and profit.
(2) Beneficiary eligibility determinations: The agency said it also plans to look more closely at states that have been found by the Office of the Inspector General to be at high risk for improperly granting improper Medicaid eligibility to enrollees. CMS may further issue potential “disallowances” of Medicaid dollars to states, based on Payment Error Rate Measurement program findings in 2022.
(3) Optimized state-provided claims data: CMS said it will harness advanced analytics and other solutions to improve Medicaid eligibility and payment data, aiming to maximize program integrity.