Preventing improper payments, which comprised $17.5 billion of Medicaid spending in 2014, represents a specific concern for the long-term health of the government-run health program, according to a report from the Government Accountability Office (GAO).
The report, which drew from previous GAO reports released between January 2005 and July 2015, identified four key issues facing Medicaid as the program enters its 50th year. The GAO lists program integrity as one of those issues, noting that Medicaid made the watchdog agency's list of high-risk programs for the last 12 years due to its large budget, high improper payment rates and insufficient oversight.
The GAO points specifically to Medicaid managed care plans that have been a target for improper payments thanks to inadequate state and federal oversight. In 2014, the GAO pointed to gaps in managed care plans, and called on the Centers for Medicare & Medicaid Services (CMS) to update program guidance and require states to audit managed care plans. In April, CMS released proposed rules that would tighten managed care regulations and improve program integrity; however, the latest GAO report reiterated the need to address previous recommendations concerning state audits and program guidance.
The GAO also addressed concerns tied to provider and enrollment fraud. In June, Seto Bagdoyan, director of forensic audits and investigative service at the GAO, testified in front of Congress that CMS needs to do more to prevent improper payments to deceased beneficiaries and banned providers. The testimony followed a report in which the GAO identified $18.3 million in concurrent Medicaid payments made to 8,600 beneficiaries in two or more states in 2011, and millions more to beneficiaries who were deceased or incarcerated. Additionally, Medicaid paid $2.8 million to providers with a revoked license.
Although the GAO indicated that CMS has implemented steps to prevent these types of overpayments, the watchdog agency indicated that CMS needs to offer states better guidance to identify deceased enrollees and improve provider screening mechanisms.
- here's the GAO report