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CMS Announces Initiatives to Strengthen Medicaid Integrity


The Centers for Medicare and Medicaid Services (CMS) recently announced several new initiatives to strengthen Medicaid integrity. 

The initiatives are primarily focused on state Medicaid agencies. However, Medicaid providers and managed care organizations should expect an eventual effect that may impact their finances and operations.

Here is a brief description of the new CMS initiatives:

  • Targeted audits of managed care organization financial reporting in some states, focusing on previously identified high-risk vulnerabilities and other behavior found detrimental to Medicaid.
  • Audits of state beneficiary eligibility determinations in some states.
  • State data quality and completeness review. 
  • Data analytics pilots to help states analyze Medicaid claim data and potential investigation target areas.
  • Pilot process to screen Medicaid providers on behalf of states on an opt-in basis.
  • Enhanced data sharing and collaboration with states – for example, the Social Security Administration’s Death Master File will be made available for states to assist with provider enrollment activities.
  • Public reporting of Medicaid scorecard performance by state along with integrity performance measures.
  • Medicaid provider education to reduce improper payments.

Impact on Managed Care Organizations and Providers

An analysis in summarized the impact of these initiatives as CMS adds pressure to states.

The states will apply pressure for accuracy and for compliance with Medicaid requirements on managed care organizations and providers. Providers should review their compliance plans to be ready for contact from state Medicaid. 

In addition to improving Medicaid accuracy and compliance, another intended consequence of the initiatives may be to slow the dramatic increase in federal Medicaid expenditures that was experienced between 2013 and 2016 – a huge 38% increase.

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Categories: Knowledge Center, Medicare and Medicaid

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