Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

GAO Recommends Changes to Medicaid Reimbursement Technology

By Jacqueline DiChiara

- A new United States Government Accountability Office (GAO) survey of the Medicaid program integrity systems in ten nationwide areas found there is a substantial puzzle piece missing within the world of information technology (IT) and Medicaid reimbursement technology. Still yet to be determined is a means of quantifying savings garnered through fraud detection and improper payment.

GAO reviewed ten selected states’ use of IT systems to determine how the efforts from each thwarted and identified improper Medicaid reimbursements.

Some jurisdictions did not meet generalized IT requirements

Three states were operating Medicaid Management Information Systems (MMIS) that had been initially implemented two decades ago.

Seven states had implemented additional systems, such as data analytics and decision support systems for complex multiple claim review and fraud identity.

Officials from nine states who administered fee-for-service plans used the systems to complete pre-payment and post-payment claim reviews. Nine used the Surveillance and Utilization Review Subsystem (SURS) to identify any suspicious provider behavior activity that went unnoticed during prepayment claims data review.

GAO’s reimbursement findings require further review

The systems’ effectiveness for program integrity purposes among the states is not yet tangibly defined. CMS does not yet require states to measure or report the systems’ quantifiable benefits, such as the amount of money saved or recovered.

Only three of the ten states measured benefits at all.

Without this needed information on quantifiable benefits, CMS does not know how effective the systems actually are in preventing and detecting improper payments.

The ten states primarily executed MMISs to administer Medicaid as a fee-for-service program with providers filing reimbursement claims for each patient service.

Officials in seven states administered managed care plans with a fixed monthly reimbursement amount. One state administered Medicaid solely as managed care.

Officials from nine states who administered fee-for-service plans said the systems helped execute pre-payment and post-payment claim review.

CMS requires MMIS to allow functionality to determine Medicaid provider participation eligibility. This includes cross-referencing license and sanction information with other states and federal agencies to identify ineligible providers.

GAO requests clearer MMIS implementation requirements

GAO recommended CMS formally enact such a requirement to measure cost reduction or cost avoidance associated with the use of integrity systems. “The Secretary of Health and Human Services should direct the Administrator of CMS to require states to measure quantifiable benefits, such as cost reductions or avoidance, achieved as a result of operating information systems to help prevent and detect improper payments,” the report states.

CMS concurred with such a recommendation. GAO is waiting to confirm further actions.



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