CMS has touted an upgraded reporting system to spot overpayments, but only 18 states have implemented it so far.
Giving states increased latitude over how they operate Medicaid gives them the ability to tailor programs to local needs, but this also makes it harder for CMS to spot problems that can lead to improper payments, according to a new report from the Government Accountability Office (GAO).
Lack of uniform data—something CMS has acknowledged—is a major barrier to good oversight, one that the report found must be addressed sooner rather than later. In particular, CMS has pinned its oversight hopes on the Transformed Medicaid Statistical Information System (T-MSIS). As of October, only 18 states were taking part; however, these accounted for 70% of the Medicaid population, according to the report.
The report released Monday comes as Congress wants to rethink Medicaid expansion under the Affordable Care Act (ACA), a law that has vastly expanded the Medicaid population and, at the same time, given states increased flexibility through waiver programs to customize Medicaid to state needs. Congress will likely weigh whether Medicaid should be run as a block grant program, a change that would only increase the lack of uniformity among state programs.
GAO found that in 2015, Medicaid accounted for $347.5 billion in federal spending and $206.8 billion in state matching funds. GAO estimated that improper spending reached $36.3 billion in Medcaid in 2016, up from $14.4 billion in 2013, the year before expansion took full effect. That’s not to say that CMS is not cracking down on fraud; it is, and it used data modeling to do so.
Still, the GAO found:
GAO sees value in the T-MSIS improvements—it just wants to see them implemented at a quicker pace. Under T-MSIS, states make the following reporting changes:
This was the second GAO report in a week to examine how well Medicaid is doing at making sure only those eligible for the program get benefits, at bolstering oversight of Medicaid managed care, at making sure providers are eligible to take part in the program, and at making sure Medicaid and the healthcare exchanges are coordinating to make sure people cannot get duplicate coverage. In a January 31, 2017, report, GAO found that CMS was taking steps to improve oversight, but not a pace that would catch enough overpayment and fraud, given the growth of the system. For starters, CMS needs better coordination with states, the report found.
“States, which are responsible for the day-to-day administration of the Medicaid program, are the first line of defense against improper payments,” the report said.
When it comes to double coverage, the investigators wrote, “CMS has conducted checks to identify individuals with duplicate coverage, and plans to complete these checks at least 2 times per coverage year, which has the potential to save federal—as well as beneficiary—dollars. However, CMS has not developed a plan for assessing whether the checks and other procedures—such as thresholds for the level of duplicate coverage deemed acceptable—are sufficient to prevent and detect duplicate coverage.”
ACOs’ Focus on Rooting Out Fraud Aligns With CMS Vision Under Oz
April 23rd 2025Accountable care organizations (ACOs) are increasingly playing the role of data sleuths as they identify and report trends of anomalous billing in hopes of salvaging their shared savings. This mission dovetails with that of CMS, which under the new administration plans to prioritize rooting out fraud, waste, and abuse.
Read More
New Research Challenges Assumptions About Hospital-Physician Integration, Medicare Patient Mix
April 22nd 2025On this episode of Managed Care Cast, Brady Post, PhD, lead author of a study published in the April 2025 issue of The American Journal of Managed Care®, challenges the claim that hospital-employed physicians serve a more complex patient mix.
Listen
Personalized Care Key as Tirzepatide Use Expands Rapidly
April 15th 2025Using commercial insurance claims data and the US launch of tirzepatide as their dividing point, John Ostrominski, MD, Harvard Medical School, and his team studied trends in the use of both glucose-lowering and weight-lowering medications, comparing outcomes between adults with and without type 2 diabetes.
Listen
Upadacitinib Shows Promise for Hard-to-Treat Crohn Disease
April 23rd 2025Upadacitinib showed promising results in achieving clinical and endoscopic remission in people with moderate to severe Crohn disease, including those previously treated with advanced therapies, offering a potential second-line treatment option with a manageable safety profile.
Read More
Higher Weight-Adjusted Waist Index Tied to Greater Mortality Risk in Patients With Osteoarthritis
April 23rd 2025Researchers consider the weight-adjusted waist index a more precise predictor of mortality risk in patients with osteoarthritis than traditional obesity measures, like body mass index.
Read More