Medicaid managed care organizations weak on reporting fraud, abuse, probe concludes


Managed care organizations can do more to improve Medicaid integrity, according to a report from the HHS Office of Inspector General.

The report examined 2015 data from managed care organizations in 38 states. It also examined data from interviews with five selected managed care organizations, as well as data from interviews with officials from the state Medicaid agencies in those same five states. Overall, the inspector general found managed care organizations have room for improvement when it comes to identifying and addressing Medicaid fraud and abuse.  

"Although the number of cases varied widely, some MCOs identified and referred few cases of suspected fraud or abuse to the state in 2015, and not all MCOs used proactive data analysis — a critical tool for fraud identification," the office wrote.

Managed care organizations also did not typically notify state officials when actions were taken against fraud or abuse suspects, including the termination of provider contracts, according to the inspector general. Additionally, the office found managed care organizations sometimes failed to identify and recover Medicaid overpayments.

"These weaknesses may limit states' ability to effectively address fraud and abuse in their Medicaid programs," the inspector general concluded. "At the same time, selected states employ a number of strategies to address MCOs' weaknesses and improve their efforts. These include providing education and training and facilitating information sharing among MCOs. States also reported using encounter data to conduct their own proactive data analysis, but these data have limitations."

Based on its findings, the inspector general  recommended CMS and states collaborate to improve efforts by managed care organizations to identify fraud or abuse. It also recommended CMS and states work to "increase MCO reporting to the state of corrective actions taken against providers suspected of fraud or abuse," and "clarify the information MCOs are required to report regarding providers that are terminated or otherwise leave the MCO network."

To read all of the inspector general's recommendations, click here.



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