The federal government should do more to help states ensure the accuracy and integrity of their payments to Medicaid managed care organizations and the payments those Medicaid managed care organizations make to health care providers.
This is the conclusion reached in a new study of Medicaid managed care performed by the U.S. Government Accountability Office at the request of the Permanent Subcommittee on Investigations of the Senate Committee on Homeland Security and Government Affairs.
The GAO study identified six payment risks among various transactions between state governments, Medicaid managed care organizations, and health care providers. The two biggest risks, the GAO concluded, were:
- incorrect fee-for-service payments from MCOs, where the MCO paid providers for improper claims, such as claims for services not provided; and
- inaccurate state payments to MCOs resulting from using data that are not accurate or including costs that should be excluded in setting payment rates.
The GAO traces some of these problems to a delay in the Centers for Medicare & Medicaid Services’ planned Medicaid managed care guidance to states; limited implementation of new auditing practices CMS introduced in 2016; and CMS’s failure to account for overpayments to providers when it reviews state capitation rates for Medicaid managed care plans.
To address these shortcomings, the GAO report recommends that CMS:
- expedite issuing planned guidance on Medicaid managed care program integrity;
- address impediments to managed care audits; and
- ensure states account for overpayments in setting future MCO payments.
CMS agrees with these recommendations.
Learn more about the study – why it was undertaken, how it was conducted, what it found, and what it recommended – by going here to see the GAO report Medicaid Managed Care: Improvements Needed to Better Oversee Payment Risks.