Half of the top 10 management and performance challenges identified by the Office of Inspector General (OIG) in fiscal year 2015 have fraud, waste and abuse implications, according to a report released Tuesday.
The OIG lists Medicaid expansion, Medicare Parts A and B, and prescription drug utilization as key management concerns for the Centers for Medicare & Medicaid Services (CMS). Additionally, the OIG highlighted some potential fraud challenges in overseeing health insurance marketplaces and federal payment reforms.
With 29 states expanding Medicaid eligibility, fraud and abuse remains a top management priority, according to the OIG. The watchdog agency cited Medicaid's 6.7 percent improper payment rate in 2014 linked primarily to payments made to ineligible individuals. The OIG recommended that CMS "continue to develop robust oversight for the Medicaid expansion," particularly regarding eligibility requirements. Additionally, more robust Medicaid data will help root out ineligible providers. Earlier this year, the Government Accountability Office called on CMS to do more to prevent Medicaid fraud involving banned providers and improper payments to deceased beneficiaries.
Reducing improper payments and preventing and deterring fraud are two ongoing challenges within Medicare Part A and B, according to the report. While the Health Care Fraud and Abuse Control Program has helped recover improperly paid claims, CMS needs to do more to identify and recover improper payment faster and provide better oversight of fraud contractors. In September, President Barack Obama's budget director called for "new and innovative ways" to reduce improper payments.
The OIG continues to point to vulnerabilities within the Part D program, including the fact that plan sponsors are not required to report fraud and abuse activities. Drug diversion and questionable utilization were two other key concerns, and although CMS has taken steps to prevent pharmacy billing fraud and overutilization, more needs to be done to prevent drug abuse, which could benefit from a Medicare lock-in policy.
The OIG also highlighted challenges surrounding eligibility determinations with health insurance marketplaces and payments reforms that could lead to new fraud schemes, particularly within Medicare Advantage plans.
- read the OIG's report
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