Government lacks data to ensure proper oversight of Medicaid

CMS aims to improve the integrity of the program through advanced analytics, says Administrator Seema Verma.

The federal government’s efforts to combat Medicaid fraud and overpayments, which totaled nearly $37 billion in fiscal year 2017, must be strengthened by improving its data oversight system.

That’s the message that the Government Accountability Office and lawmakers delivered on Tuesday before a Senate hearing.

The Medicaid program, which provides healthcare for more than 73 million low-income Americans, has been on the GAO’s “high risk list” since 2003 because of concerns about the adequacy of federal oversight and the program's vulnerability to fraud. However, the Centers for Medicare and Medicaid Services has not been making progress in addressing the problem of fraud and overpayments, critics contend.

“Government watchdogs have warned CMS for 15 years about Medicaid’s vulnerability to fraud and overpayments, and the committee has found that CMS has not taken basic steps to fix the problems,” said Sen. Ron Johnson (R-Wis.), chairman of the Homeland Security and Governmental Affairs Committee. “As a result, Medicaid overpayments to providers are $37 billion per year, a 157 percent increase since 2013. Increasingly, the program is funding fraudsters whose primary goal is self-enrichment.”

Data from the Transformed Medicaid Statistical Information System (T-MSIS) was supposed to help ensure the effective administration and oversight of the Medicaid program, including enhancing the ability to identify potential fraud, waste and abuse.

However, Gene Dodaro, comptroller general of the United States and head of the GAO, told the Senate committee that more needs to be done to collect accurate, complete and comparable data from all states. While CMS has made progress toward implementing T-MSIS, the data are not sufficient to enable the agency or states to provide effective oversight of the program, according to Dodaro.

Also See: GAO contends oversight is lacking for national repository of Medicaid data

Nonetheless, CMS Administrator Seema Verma testified that, as of last month, all states, the District of Columbia and Puerto Rico are now—for the first time—submitting data on their Medicaid programs to T-MSIS.

“We are working to optimize how we use state-provided claims and provider data in our program integrity efforts,” said Verma in her testimony. “We are now shifting from simply collecting the data to using advanced analytics and other innovative solutions to improve data and maximize the potential for program accountability and integrity purposes.”

In an effort to address some of these issues, she pointed out that earlier this year the agency announced a Medicaid Program Integrity Strategy that seeks to improve Medicaid eligibility and payment data.

As a result, Verma noted that CMS will have the ability to identify instances such as a Medicaid beneficiary “receiving more hours of treatment than hours in a day or other flags that necessitate further investigation.”

Dodaro said GAO will continue to monitor the agency’s efforts to improve its data systems and their use for oversight of the Medicaid program.

“I think it would be appropriate to ask CMS to regularly report to the Congress on the quality of the data and ask GAO to evaluate it as well,” he added.

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