Breaking Down the CMS Medicaid Integrity Strategy

Healthcare News

What is the CMS Medicaid Integrity Strategy?

The Centers for Medicare & Medicaid Services (CMS) developed the Medicaid Integrity Strategy to combat abuse, fraud, and the waste of Medicaid dollars. The Medicaid Integrity Program was the first comprehensive Federal strategy aimed at combating the abuse of the Medicaid program. This program aims to keep Medicaid sustainable for years to come, especially with Medicaid spending increasing dramatically over the past decade.

Increased growth requires increased responsibility and oversight of Medicaid spending to ensure those who need the program resources are able to receive it. While this largely remains under the responsibility of each state, CMS must work in partnership with states to increase accountability and transparency. CMS has now announced new initiatives to create greater accountability for Medicaid program integrity performance. Below, we have outlined these new initiatives so that your orthopedic or radiology practice is well prepared.

Main Focuses of New Medicaid Program Integrity Initiatives

1. Targeted Audits

Targeted audits will be conducted on the state level, looking into managed care organization financial reporting. The goal of this is to mitigate risk and checking to ensure claims experience matches what plans are reporting. High-risk vulnerabilities will be the target of these audits.

Additionally, CMS will conduct new audits of state beneficiary eligibility determinations in states previously reviewed by OIG. This may include a review of whether beneficiaries were found eligible for the correct Medicaid eligibility category.

2. Increased Data Sharing

Data sharing is a vital part of oversight and transparency throughout CMS. Through the new Medicaid Integrity Strategy initiatives, all 50 states and Puerto Rico will be submitting data to TMSIS – the Transformed Medicaid Statistical Information System. CMS will take this data analytics and validate how complete the data is and what it tells us. With advanced analytics utilized throughout the future, CMS hopes that TMSIS can improve and that the program integrity is maximized.

CMS will also be sharing more information with states, including the Social Security Death Master File. This will support state provider enrollment activities by making information readily available and more transparent than ever before.

Data sharing will also come in the form of public state performance reports. The CMS created the Medicaid Scorecard that reports how each state performs on Medicaid programs and will eventually also include integrity performance measures.

3. Greater Education

In addition to targeted audits and increased data sharing, another new initiative will be to provide greater education to Medicaid Providers. A substantial source of waste in Medicaid is due to improper payments. CMS will aim to provide education on this topic in order to reduce instances of incorrect billing and education topics focused on creating accurate billing reports.

4. Robust Analytic Tools

CMS will be sharing its knowledge on analyzing large and complex sets up Medicare data in order to help individual states manage their analytics. Analytics are vital to the integrity of any large program as they help entities to assess data and come up with insights that can be used to improve processes. CMS plans to help states apply algorithms and insights to analyze Medicaid state claim data and identify potential areas to target for investigation.

Support for Medicaid Integrity Program

The Medicaid Integrity Program is working to provide more effective state support to prevent and reduce Medicaid provider fraud and abuse through these new initiatives. If your practice has concerns about Medicaid spending or would like to have an internal audit conducted, Health Information Services (HIS) is here to help get you on track to become more efficient and compliant. Contact us today to learn more!