June 27, 2018

CMS Announces Enhanced Medicaid Integrity Strategy

On June 26, 2018, the Centers for Medicare & Medicaid Services (CMS) announced new and enhanced initiatives to improve Medicaid program integrity by seeking greater transparency and accountability with the help of strengthened data and robust analytic tools.

CMS cites program expansion among several factors contributing to Medicaid spending growth from $456 billion in 2013 to $576 billion in 2016. Much of this growth came from the program’s federal share, which grew from $263 billion to an estimated $363 billion during that same three-year period, according to CMS. Though responsibility for proper payments in Medicaid primarily lies with the states, oversight of Medicaid requires a partnership, it noted.

CMS plays a significant role in supporting state efforts to meet high program standards. Administrator Seema Verma has established flexibility, accountability and integrity as the three pillars to guide CMS’ work in the Medicaid program. “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,” she said in recent public announcement. “Beneficiaries depend on Medicaid, and CMS is accountable for the program’s long-term viability.”

The initiatives will include stronger audit functions, enhanced oversight of state contracts with private insurance companies, increased beneficiary eligibility oversight and stricter enforcement of state compliance with federal rules.

A snapshot of the Medicaid Integrity Initiative includes the following actions: 

  • Conducting new audits of State Beneficiary Eligibility Determinations
  • Optimizing state-provided claims and provider data
  • Using data innovation to empower states and to conduct data analytics pilot programs
  • Reporting state performance on an enhanced Medicaid Scorecard
  • Providing Medicaid provider education to reduce improper payments

To learn more, see the CMS Medicare Program Integrity Strategy Fact Sheet.

The ACR monitors the Medicaid landscape through the Medicaid Network, led by Raymond K. Tu, MD, FACR. The ACR tracks local Medicaid programs and reviews local coverage policies, and our network's relationships with large, multistate Medicaid Managed Care Organizations (MCOs) allows the College to have valued input in reviewing and commenting on medical coverage policies. See the ACR Medicaid Resources Page for guidance and information.