GAO Study Flags Risks of Fraud in Medicaid Managed Care

According to Bloomberg Government:

“Medicaid managed care plans are in the hot seat over whether they’re susceptible to fraudulent or wasteful payments.

A government watchdog is shining a light on flaws and challenges putting the delivery system’s dollars at risk, such as state payments based on inaccurate data and plan payments for care that isn’t provided or patients who aren’t eligible. Oversight needs to be stronger to avoid these problems, according to the Government Accountability Office.

The Health and Human Services inspector’s general office also found shortcomings in Medicaid managed care payments earlier this summer as the sector has come increasingly under scrutiny. Managed care is now the dominant delivery system for Medicaid, covering more than 80 percent of beneficiaries, figures from the Medicaid and CHIP Payment and Access Commission show. And nearly half of Medicaid spending ($171 billion in 2017) goes to managed care plans that run the benefits at a monthly capitated per-enrollee cost to the state. They include major health insurers Centene and UnitedHealthcare.

The GAO noted federal and state program integrity initiatives have mostly gone to fee-for-service Medicaid instead of managed care, making understanding of potential issues in managed Medicaid’s payments less clear. With the government’s spotlight comes a turning point for managed care that will likely see states, plans, and Medicaid officials making hefty improvements in the next five years to resolve these concerns, Randi Siegel, an attorney at Manatt, Phelps & Phillips in New York, told Bloomberg Law.

‘A lot of this failure around providing appropriate program integrity oversight is less a result of bad actors but more just growing pains with the proliferation of Medicaid managed care,’ Siegel said.

Now’s the moment when federal and state agencies should also start looking further down the line to what’s next and to build program integrity oversight to address where managed care will be in 10 years, she added. That includes tackling oversight for how Medicaid plans cover value-based payments and socioeconomic factors determining health.

‘We can’t stay static as we try to improve the current state,’ she stressed.”

Side note: Speaking of Managed Care – A new rule is under review at the White House Office of Information and Regulatory Affairs. This rule would address Medicaid managed care regulatory framework as it comes to the termination and enrollment of providers.