Legislation Could Lower Medicaid Abuse, Waste and Fraud

29 Apr Legislation Could Lower Medicaid Abuse, Waste and Fraud

The Government Accountability Office (GAO), the watchdog for the U.S. Congress, determined that Medicaid and Medicare as programs with potential for a high risk of abuse, waste and fraud. In the case of Medicaid, the GAO says inadequate fiscal oversight might result in improper expenditures. A complex Medicare system could result in erroneous payments.

The Centers for Medicare & Medicaid Services (CMS), the Department of Health and Human Services (HHS) that administers these two programs, determined in 2010 that over $70 billion was paid out incorrectly. By applying previous GAO suggestions, recently passed laws and current agency procedures, CMS could accomplish five tactics already outlined by the GAO as ways to diminish inappropriate Medicaid and Medicare payments, thereby lessening fraud.


Bolster Five Areas to Fight Medicaid and Medicare Abuse

The following are five tactics for reducing improper payments within the Medicaid and Medicare systems:

1.     Fortify Procedures and Standards for Enrolling Providers – If procedures and standards used to enroll providers were toughened, fraudulent activities could be eliminated. The Patient Protection and Affordable Care Act (PPACA), passed into law in 2010, bolsters parts of the enrollment policies for Medicaid and Medicare. By executing PPACA provisions, CMS is scoring providers based on risk and demanding more scrutiny of high-risk providers.

2.    Examining Claims Prior to Payment – By proactively examining claims before they’re paid, payments can be made with more accuracy. A PPACA requirement calling for automatic prepayment controls is being required by all states from the CMS. Also, CMS is making contractors use predictive modeling analysis on claims in order to create better controls prior to payment. But, some GAO suggestions to better the review of claims prior to payment have not been employed by the CMS.

Review of Susceptible Claims – Urgently checking claims that were already paid, but deemed as at risk for being inappropriate, could result in a quick recoup of overpayments. Recovery Audit Contractor (RAC) programs in Medicaid and Medicare has been implemented by CMS. The problem is that CMS contractors persist on reviewing claims, while the GAO says that CMS should insist on making the review of high-risk claims after payment the highest priority for CMS’s contractors.

4.     Better Oversight on Contractors – Imperative to an improvement in Medicaid and Medicare fraud prevention is a sharper control of CMS’s contractors. In this endeavor, CMS is adopting suggestions made by the GAO to advance the supervision of prescription drug plan abuse and fraud.

5.     Creating a Tough Manner for Weeding Out Vulnerabilities – If policies are in place, which identify susceptible areas of improper payments, fast changes can alter fraudulent claims. However, CMS has failed to offer a vigorous process for identifying vulnerable areas recognized by RACs. Furthermore, CMS did not apply GAO proposals to better this process. Plus, advice from CMS to states related to Medicaid RAC programs fails to address a corrective action for the susceptibility of improper payments. Implementing already suggested procedures could lead the way to fewer improper payments in the future.