Insight: Strategies for Compliance Oversight and Program Integrity in Medicaid Managed Care

By: Anthony J. Fiori | Randi Seigel | Thomasina P. Anane
– Bloomberg Law

Program integrity and compliance activities are meant to ensure that federal and state taxpayer dollars are spent appropriately on delivering quality, necessary care and preventing fraud, waste and abuse in federal healthcare programs. In the past four months, the Government Accountability Office (GAO) and Office of Inspector General (OIG) have issued a barrage of reports scrutinizing Medicaid programs and their oversight of program expenditures. Specifically, they assert that, despite Medicaid’s significant shift in the past decade from a fee-for-service (FFS) to a managed care model, related oversight and compliance efforts have been slow to follow. A May 2018 GAO report and another GAO report released in July 2018 allege that the efforts of both the Centers for Medicare & Medicaid Services (CMS) and states with respect to providing proper program payment and integrity guidance have continued to focus on FFS while paying little attention to Medicaid managed care. On June 27, CMS Administrator Seema Verma announced the agency’s initiatives to strengthen Medicaid managed care program integrity to specifically address the GAO’s and OIG’s concerns.

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