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CMS: Data Analytics will Strengthen Medicaid Program Integrity

Data analytics tools will support new audits to identify improper payments, ensure eligibility, and further strengthen Medicaid program integrity.

New CMS initiatives will strengthen Medicaid Program Integrity

Source: Thinkstock

By Jessica Kent

- New CMS initiatives will utilize advanced data analytics tools, quality data, and increased transparency to strengthen Medicaid program integrity and ensure the sustainability of the program for all beneficiaries.

In recent years, Medicaid has expanded and program spending has increased rapidly, growing from $456 billion in 2013 to an estimated $576 billion in 2016. The federal share of Medicaid spending has increased as well, from $263 billion to an estimated $363 billion during this period.

“The initiatives released today are essential to help strengthen and preserve the foundation of the program for the millions of Americans who depend on Medicaid’s safety net. With historic growth in Medicaid comes an urgent federal responsibility to ensure sound fiscal stewardship and oversight of the program,” said CMS Administrator Seema Verma.

“These initiatives are the vital steps necessary to respond to Medicaid’s evolving landscape and fulfill our responsibility to beneficiaries and taxpayers.”

Among the new initiatives is the optimization of state-provided claims and provider data. CMS will use advanced data analytics to improve Medicaid eligibility and payment monitoring.

Every state, along with Washington, DC and Puerto Rico, will submit enhanced data to CMS.In the coming months, CMS will validate the data for quality and completeness.

The new initiatives also include stronger audit functions, which will allow CMS to begin auditing some states using comparisons between the amount they have spent on clinical services and quality improvement and how much funding is used for administration costs and profits.

Overall, audits will address eligibility issues and risks for improper payments identified by the Government Accountability Office (GAO), Office of the Inspector General (OIG).

Current regulations allow CMS to begin to issue potential disallowances to states based on Payment Error Rate Measurements (PERM) program findings. The PERM program evaluates improper payments in Medicaid on a rolling three-year basis and produces national and state-specific improper payment rates.

To further drive CMS’ efforts in strengthening and sustaining Medicaid, Verma has named three pillars to guide CMS’ work in the program: Flexibility, Accountability and Integrity.

“As we give states the flexibility they need to make Medicaid work best in their communities, integrity and oversight must be at the forefront of our role. Beneficiaries depend on Medicaid and CMS is accountable for the program’s long-term viability,” she said.

“As today’s initiatives show, we will use the tools we have to hold states accountable as we work with them to keep Medicaid sound and safeguarded for beneficiaries.”

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