CMS boosting Medicaid audits, oversight to 'strengthen safety net'

CMS is increasing Medicaid audits and oversight of the program, according to a June 26 announcement.

The agency noted Medicaid spending increased from $456 billion in 2013 to an estimated $576 billion in 2016, with Medicaid expansion being among the contributing factors. Given this trend, the agency said it decided to strengthen the program’s integrity through three new initiatives that include increasing audits, greater oversight of contracts between states and private insurers, greater oversight of beneficiary eligibility, and boosting efforts to ensure states comply with federal rules. 

"The initiatives released today are essential to help strengthen and preserve the foundation of the program for the millions of Americans who depend on Medicaid's safety net. With historic growth in Medicaid comes an urgent federal responsibility to ensure sound fiscal stewardship and oversight of the program," said CMS Administrator Seema Verma. "These initiatives are the vital steps necessary to respond to Medicaid’s evolving landscape and fulfill our responsibility to beneficiaries and taxpayers."

The initiatives specifically involve auditing states for federal match funds and medical loss ratios, according to the agency. CMS said some states will be audited based on how much money is spent on clinical services and quality improvement compared to administration and profit. Officials noted the MLR audits will include reviewing states' rate setting.

CMS said it also plans to "audit states that have been previously found to be high risk by the [HHS] Office of Inspector General to examine how they determine which groups are eligible for Medicaid benefits. These audits will include assessing the effect of Medicaid expansion and its enhanced federal match rate on state eligibility policy."

The agency also said it will use advanced analytics to improve data on Medicaid eligibility and payment.


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