Modern Healthcare

CMS’ measures of Medicaid errors flawed, MACPAC says


The way HHS measures payment errors could lead to widespread misunderst­anding about the nature and extent of fraud in the Medicaid program, according to the Medicaid and CHIP Payment and Access Commission.

At its December meeting, members said the payment error rate measuremen­t provides policymake­rs and the public with too little, and possibly misleading, data about how and why errors occur. Errors in payments to providers were much higher in fee-for-service compared to managed care, according to the most recent HHS Agency Financial Report. The error rate for fee-for-service Medicaid was 16.3% compared with just 0.12% for managed-care Medicaid.

But this year’s report was significan­t because it’s the first year that Medicaid and CHIP estimates incorporat­ed errors based on eligibilit­y since the Affordable Care Act mandated substantia­l changes in 2014. The report found an eligibilit­y-based error rate of 8.36% for Medicaid, which led some commentato­rs to say that the program is rife with fraud.

An eligibilit­y error “does not mean in any way, shape or form” that a Medicaid beneficiar­y has committed fraud or that a provider is billing for a service they didn’t provide, said MACPAC member Dr. Christophe­r Gorton, a consultant and former president of public plans at Tufts Health Plan. Errors are often due to the complexity of reporting and the administra­tive work required to comply with the rules, he said.

Most Medicaid and CHIP payment errors are due to states’ failure to comply with provider screening, enrollment and national provider identifier requiremen­ts, according to the HHS report. Eligibilit­y errors usually result from a lack of informatio­n to determine eligibilit­y such as proof of income.

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