Medicaid Integrity Program

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Medicaid Integrity Program

• Deficit Reduction Act Initiatives

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DRA MEDICAID INTEGRITY PROGRAM

• 5-Year Comprehensive Medicaid Integrity Plan
• http//www.cms.hhs.gov/DeficitReductionAct/
• Audit Medicaid Providers
• Annual Reports to CongressReturn on Investment
• National Medicaid Program Integrity Advisory
  Committee
• Coordinate with States and Other Federal Agencies

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Contracts for claims review, audits, overpayment
identification education

• Audit Providers
• Refer suspected fraud cases to OIG
• Regional Contracts
• Recover federal share of overpayments
• Assist states in collection of overpayments
• Educate Providers

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Effective Support and Assistance to States

• Program Integrity Protocols Reviews
• Fraud Science/Research
• Training Opportunities
• Regional Conference Calls
• CMS Field Staff

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Additional CMS Resources

• 100 New CMS FTEs
• 20 Medi/Medi and PERM
• 80 CMS PI Central Office and Field Ops
• 5 million in FFY 06
• 50 million in FFY 07 and FFY 08
• 75 million annually by FFY 09

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CMS Medicaid Integrity Group

• Division of Medicaid Integrity Contracting
• Oversee strategic contractors
• Procure and monitor Medicaid contracts
• Division of Fraud Research Detection
• Investigate emerging trends
• Develop prevention measures
• Division of Field Operations
• State PI oversight
• Technical assistance

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OTHER DRA PROVISIONS
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Medi/Medi Expansion

• Medi/Medi Combines Medicaid and Medicare Data
• 10 States Participate
• DRA Encourages National Expansion
• DRA Provides 60 Million Annually
• State Coordinating Committee
• Provision in 2007-09 WI Budget Proposal

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Assistance to OIG

• 25 Million Annually
• Additional Training
• New Resources
• Additional Audits
• Improve Fraud Referral Processes

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False Claims Education

• Entities Receiving or Paying Over 5 million in
  Annual Medicaid Payments Must Develop and
  Maintain an Employee Education Program Related to
  Federal FCA, State FA Programs and Whistleblower
  Provisions
• Condition of Participation in Medicaid
• Also Applies to Contractors
• State Enforcement

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State False Claims Act

• Encourage States to Enact FCAs
• Acts Must Meet Federal Standards
• State Using a State FCA May Retain a Higher
  Percentage of Recovered Overpayments
• Language in 2007-09 WI Budget Proposal

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MIP Implementation

• Ongoing consultations with partners
• Medicaid Advisory Committee
• Strategic contractors
• Medicaid Integrity Audit Program
• State Program Integrity Assessment
• Statutory regulatory review
• Education and training

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What Does MIP Mean for States?

• Previous to DRA, CMS provided broad policy
  guidance and limited oversight of PI functions
• MIP requires closer review of state actions
• MIP provides funding for additional assistance,
  training and support
• MIP requires that CMS audit providers
• MIP requires that CMS coordinate its activities
  with state and other federal agencies

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MIP Challenges

• Ensuring coordination with state audit activities
  and OIG audits
• Ensuring understanding of different state program
  requirements and processes
• Identifying and sharing best practices
• Identifying states needs and providing resources
  to best address those needs
• Avoiding negative impact on access to care

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CMS Referral Training

• Update and Publish MFCU/Program Integrity Best
  Practices Manual
• --Listing of MFCU and PI Directors
• --Rules and Responsibilities
• --Description of CMS Integrity Program
• --Sample MOUs
• --False Claims Act Information
• --Referral Techniques
• --Cross Training Events
• Other Training Opportunities

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QUESTIONS