With an insurer as big as the Centers for Medicare and Medicaid Services (CMS), it’s an inevitability that some Medicaid claims in the system will get lost or misinterpreted. What is far less acceptable, however, is when states intentionally manipulate this data in order to avoid paying their portion of the charge. It is for this exact reason that CMS has pledged to conduct targeted audits of its sponsors in hopes of cracking down on some of these improper Medicaid payments.
While CMS administrator Seema Verma used the 2018 Medicaid Managed Care Summit to congratulate sponsors on their ability to provide quality Medicaid care, she had no reservations about also discussing her plans for the targeted audits that are to come.
“Transparency must also extend to our health plan partners,” said Verma. “This room understands well that nearly all newly eligible individuals in Medicaid are served through managed care organizations. I’m putting you on notice now: CMS will begin targeted audits to ensure that provider claims for actual health care spending matches what the health plans are reporting financially.”
Although Verma did not elaborate, the larger implication of this announcement is that CMS has found significant examples of states not actually providing the amount of Medicaid funds they reported. As of her speech at the summit, there was no official start date for these targeted audits.
If you work for a practice or facility that sees a high number of Medicaid patients, you may want to follow any news regarding these audits, as they may affect some of your reimbursement in the future. While there is no guarantee that CMS will find what they are looking for and enact major changes, it is always better to keep up with these stories so that you and your coworkers can stay on top of any coming regulation changes.