GAO Urges CMS Review Incomplete, Inaccurate Medicaid Payments
By - Ensuring actionable results via the interpretation of cached information about Medicaid provider payments is not always a simple task. Although it is possible even severely flawed payment information can offer some sort of a general baseline for enhanced revenue cycle knowledge, precision amplifies communicative depth.
States pay healthcare providers under Medicaid and in turn collect federal matching funds. Incentives exist regarding excessive Medicaid payments to various institutional providers. According to federal law, payments must be cost-effective and economical. Payments that are so large they exceed costs raise red flags as to their intent and may be subject to further investigation.
Such recent investigations are prompting the appearance of red flags left and right. Inaccurate and incomplete Medicaid payment data is flawed, according to the Report to Congressional Requesters released by The US Government Accountability Office (GAO). As a result, assessments of total payments made to specific individual hospitals cannot be effectively completed, GAO states.
Highlights of GAO’s inconsistent, inaccurate findings
Perhaps one cause stems from a concrete transparency void. Although states mandatorily capture payment information to individual institutional providers, states are not obliged to report this information, GAO confirms, nor are they required to report ownership information. “Inconclusive trends” and high payments warranting oversight require addressing, confirms GAO’s report.
“In Illinois, average daily payments for inpatient services were comparable for government and private hospitals, but these averages masked wide variations in daily payments for both types of hospitals,” GAO confirms. Daily payments ranged from below $600 to almost $10,000 for local government hospitals, says GAO, and between $750 and over $11,000 for private hospitals. GAO additionally adds, “One selected hospital in Illinois and two in New York had Medicaid payments that exceeded the local government hospitals’ total operating costs, including costs associated with all services provided to all patients they served.”
Limitations with CMS create payer shortcomings
The Centers for Medicare & Medicaid Services (CMS) and the Department of Health and Human Services (HHS) maintain accountability for the management and general supervision of Medicaid payments. Both organizations face limitations regarding insupportable payment information and a lack of both a policy and process for accessing payments to providers.
“CMS does not collect provider-specific payment and ownership information. CMS also lacks a policy and standard process for determining whether Medicaid payments to individual providers are economical and efficient,” maintains GAO. “Excessive state payments to individual providers may not be identified or examined by CMS,” GAO adds, in reference to CMS’ failure to identify sizable overpayments to a pair of New York hospitals until such information was confirmed and reviewed for appropriateness by GAO.
GAO urges CMS to take action. “GAO recommends that CMS take steps to ensure states report provider-specific payment data, establish criteria for assessing payments to individual providers, develop a process to identify and review payments to individual providers, and expedite its review of the appropriateness of New York's hospital payments.”
GAO additionally recommends “CMS develop a policy establishing criteria for when such payment at the provider level are economical and efficient [and] after criteria are developed that CMS develop a process for identifying and reviewing payments to individual providers in order to determine whether they are economical and efficient.”
GAO’s report to Congress pushes for increased oversight at numerous government-owned facilities where payments are higher than actual costs rendered. HHS confirmed agreement with the proposed ideas, stating, “HHS is evaluating ways to improve its oversight.” It is, nonetheless, hopeful Medicaid payments to individual healthcare providers can be further examined through a lens of transparency.
