CMS wants to boost authority for Medicaid investigative units

The rate of improper Medicaid payments has ballooned over the past few years—from $14.4 billion in fiscal 2013 to $29.1 billion in fiscal 2015. But the CMS hopes to further crack down on fraud by increasing the federal matching rate for states’ investigative units and expanding the scope of their authority. Comments on a draft rule that would overhaul regulations related to state Medicaid fraud control units are due Nov. 21.

In additional to offering more financial support, the CMS wants fraud units to be allowed to investigate and prosecute patient abuse or neglect in healthcare facilities, regardless of whether they receive Medicaid payments.

Comments on the draft rule have been generally positive while encouraging the agency to write a final rule that leads to greater collaboration between the fraud units and managed-care organizations. Plans are expected to help flag potential cases of fraud or abuse or even furnish information to help prosecute. But according to the Medicaid and CHIP Payment and Access Commission, plans get very limited guidance from states and fraud units.

“I’m a little, frankly, disappointed that (the CMS) didn’t at least take a whack at trying to include managed care in a more meaningful way,” Dr. Christopher Gorton, president of public plans at Tufts Health Plan and a MACPAC commissioner, said at the panel’s meeting last month.

An improper payment can occur when funds go to the wrong recipient, the right recipient receives the incorrect amount of funds, documentation is not available to support a payment or the recipient uses funds in an improper manner. The tally also includes fraudulent claims.