Waste and Fraud

The Government Accountability Office says in a Wednesday (June 6) report that CMS isn't looking closely enough at Medicaid managed care plans, including whether those plans overpay providers or have so-called unallowable costs, and the office recommended that CMS take steps to make sure it is accurately looking at Medicaid plans' improper pay rate.

Republican House Energy & Commerce leaders are asking HHS Secretary Alex Azar how he plans to fix the Medicare appeals backlog, the Medicaid improper pay rate and Medicaid financial reporting problems.

The drop in CMS' improper pay rate for fee-for-service Medicare was driven by a reduction in improper pay to home health agencies and inpatient rehabilitation facilities -- though CMS says home health companies and IRFs, along with nursing homes, were the major contributors to the 9.5 percent improper pay rate in fiscal 2017, and the HHS Office of Inspector General said program integrity is still a top management challenge for the agency.

Senate Finance ranking Democrat Ron Wyden said Friday (June 30) he is investigating whether CMS Administrator Seema Verma violated her ethics agreement by speaking to a Medicaid adviser to Arkansas’ Department of Human Services, a state covered by Verma’s ethics agreement due to her previous consulting work.

CMS is urging providers to start preparing for the new Medicare beneficiary cards without Social Security numbers that will come out next April followed by a 21-month transition period where providers can use either the current Social Security number-based claim number or the new Medicare Beneficiary Identifier.

CMS says it is considering structural improvements to the home health pre-claim review demonstration in response to stakeholder feedback, and the Center for Medicare Advocacy is gathering information on beneficiaries that have been required to wait for prior authorization or pre-claim review before receiving services.

CMS says that putting in place new Unified Program Integrity Contractors will help the agency improve its communication with states about Medicaid program integrity, but the Government Accountability Office says it is too soon to tell how and whether the new contractors will address issues such as the burden collaborative audits impose on state staff and communication issues surrounding those audits.

An internal HHS memo, dated Feb. 6, says some positions at the Office of Medicare Hearings and Appeals and Departmental Appeals Board are exempted from President Donald Trump's federal hiring freeze.

Sen. Tom Carper (D-DE) is raising concerns that President Donald Trump's federal hiring freeze could leave Medicare and Medicaid more vulnerable to fraud if HHS can't hire staff focused on program integrity, though HHS Secretary-nominee Tom Price says if confirmed he will take into account the role of fraud fighters as he works with the White House to implement the freeze.