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New, Enhanced Initiatives Target Medicaid Program Integrity

Several new or enhanced Centers for Medicare & Medicaid Services (CMS) initiatives are designed to improve Medicaid program integrity and sustainability through greater transparency and accountability, strengthened data, and innovative analytical tools.

Among the new initiatives are stronger audit functions, including a new practice of auditing some states based on the amount spent on clinical services and quality improvement versus administration and profit. CMS will conduct medical loss ratio audits, including a review of states’ rate setting. In addition, the agency is introducing new audits of state beneficiary eligibility determinations that will include assessments of Medicaid expansion and its effect on state eligibility policies.

For another initiative, CMS will use advanced analytics to optimize state-provided claims and provider data and improve Medicaid eligibility and payment data. CMS intends to work with states to ensure the accuracy and completeness of data, as well as strengthen provider education to reduce improper payments.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Rachel Schwartz is a policy associate at America's Essential Hospitals.