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GAO: Increased Oversight Necessary for Medicaid Managed Care

The Government Accountability Office (GAO) released a report on the integrity of Medicaid managed care programs, finding gaps in program integrity efforts and detailing recommendations for the Centers for Medicare & Medicaid Services (CMS). CMS estimates that Medicaid paid $14.4 billion in improper payments in fiscal year 2013. GAO was asked to examine how multiple federal and state entities ensure comprehensive Medicaid program integrity.

GAO found that despite Medicaid managed care payments increasing at a rate faster than fee-for-service (FFS) payments, state program integrity efforts have largely been focused on analysis of Medicaid FFS claims. In fact, some states have yet to begin examining Medicaid managed care. Recommendations from the GAO include the following:

  • increased oversight of program integrity efforts by CMS, requiring states to audit the appropriateness of payments to and by managed care organizations
  • updated guidance on Medicaid managed care program integrity
  • additional state support for managed care oversight, such as audit assistance from existing contractors

Please contact Xiaoyi Huang, JD, director of policy, at xhuang@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Matt Buechner is the policy and advocacy associate for America's Essential Hospitals.

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