As part of the Trump administration's ongoing war on fraud, waste and abuse in healthcare, a new report looks at how states can improve the volume of fraud referrals from managed care organizations (MCOs).
The Department of Health and Human Services Office of Inspector General released the analysis on Tuesday morning as federal regulators announced additional steps to crack down on states they believe are not adequately policing fraud.
The analysis found that while most states require MCOs to report "any potential fraud" to officials, some contracts instead called for reports of "credible allegations of fraud."
The timeframes for MCOs to make referrals also varied between state contracts, with some setting a one-day deadline and others offering plans up to 270 days. Some contracts established no specific timeframe, OIG said.
In addition, OIG found that some states did not specify in contracts steps that they could take if MCOs did not follow the referral requirements. There were also some states that did not offer training or feedback to MCOs around fraud referrals, OIG said.
"OIG and CMS have cited concerns about a lack of fraud referrals in Medicaid managed care and States’ efforts to oversee MCOs’ fraud referrals," OIG wrote in the report.
The agency made several recommendations to the Centers for Medicare & Medicaid Services, including that CMS work with states to ensure that managed care organizations are required to refer potential instances of fraud, and that contracts specify enforcement steps states can take.
OIG also recommended that CMS work with states to expand feedback to MCOs about fraud referrals, and to assess federal-level steps that could improve MCOs' referral volumes. CMS concurred with the first two suggestions and did not specify either way with the second two, though it told OIG it has taken steps toward implementing these ideas.
The OIG comes on the same day as top leaders at HHS and CMS revealed that they would withhold $1 billion in Medicaid funding from California and Minnesota, after the feds had already held back money from the states' programs earlier this year.
Earlier this month, the Trump administration also said it would withhold funding for New York's Medicaid fraud control unit, following a similar decision in Hawaii. The loss of funding for the fraud control unit could imperil other Medicaid funding.
The White House has been focused on rooting out fraud, waste and abuse across the government, spearheaded by Vice President J.D. Vance, and much of its efforts in healthcare have centered on Medicaid.