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CMS Administrator Verma: Medicaid Audits Coming

CMS Administrator Verma: Medicaid Audits Coming

Boom!

A huge bomb went off last week when Centers for Medicare and Medicaid Services Administrator (CMS) Seema Verma announced that the agency will begin targeted financial audits of Medicaid managed care insurers.

The announcement comes as no surprise to us, but still probably stunned many plans, especially those in states that have had historically lax enforcement of Medicaid regulations.

The move by CMS is tied to a number of issues:

  • The program, nationally at least, has historically had a very poor record of transparency, accountability and quality.
  • The program has been ripe with fraud, waste and abuse.
  • There is concern at the federal level that states do not administer their programs well; therefore, states may not be paying the correct matching percentage called for in federal law.
  • There has been a very poor roll-out nationally of the requirement by all Medicaid plans, and thus their state sponsors, to collect timely, accurate and complete encounter data for the services plans furnish.
  • Finally, the administration has a general animus toward Medicaid. It is pursuing several efforts, including endorsing restrictive waivers and work requirements, to control costs here. The audits are yet another method.

In her speech last Thursday, Verma did say that Medicaid managed care is the most quality-oriented way to deliver services to America’s poor and vulnerable. But the announcement is a watershed moment for CMS when coupled with the administration’s endorsement of the Medicaid mega rule proposed and largely enacted under the Obama administration. The rule went into effect mostly untouched by Trump’s CMS. It will bring a Medicare-like compliance, audit, and sanction regime to Medicaid as well as a Star quality bonus program in every state.

So, Medicaid plans that are also in Medicare will now get an extra dose of compliance, quality measurement, and audits. For those not experienced in Medicare, get ready for an accountability regime that will knock your socks off!

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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