Medicaid Managed Care Improper Payment Estimate
Learn how the AI-generated research projects were createdOverall Conclusion
The GAO report highlights that while CMS's current improper payment estimates for Medicaid managed care are near zero, they do not capture all program integrity risks. CMS has taken steps to improve oversight through audits and reviews, but additional measures and data improvements are necessary to fully address improper payments and ensure program integrity.
Source Document
Audit Scope
The audit covers the development of the improper payment estimate for Medicaid managed care, including the review of payments made by states to managed care plans, audits of providers and plans, and oversight activities conducted by CMS from 2020 to 2024 across all states and the District of Columbia, with future reviews including Puerto Rico.
Key Findings Summary
CMS has increased audits of managed care plans and providers, identifying over $33 million in overpayments, with nearly $23 million being recovered.
CMS's improper payment estimate for Medicaid managed care has been at or near 0 percent in recent years, but it does not account for all program integrity risks.
The improper payment estimate is based on reviews of a sample of payments, focusing on whether payments were made correctly based on documentation and contract terms.
View the Findings tab to see all 5 findings
AI-Assisted
AI-Generated Insight
The report underscores the importance of comprehensive oversight and data accuracy in Medicaid managed care to prevent improper payments and safeguard federal funds. Despite low estimated error rates, significant risks remain unaccounted for, necessitating enhanced audit strategies and data sharing.
Audit Objectives
Describe how CMS develops the improper payment estimate for Medicaid managed care.
Identify program integrity risks related to Medicaid managed care payments that are not captured by the PERM.
Assess CMS's oversight efforts to identify and recover improper payments in Medicaid managed care.
Audit Findings (5)
CMS has increased audits of managed care plans and providers, identifying over $33 million in overpayments, with nearly $23 million being recovered.
CMS's improper payment estimate for Medicaid managed care has been at or near 0 percent in recent years, but it does not account for all program integrity risks.
The improper payment estimate is based on reviews of a sample of payments, focusing on whether payments were made correctly based on documentation and contract terms.
Program integrity risks not captured include payments for services not provided, to ineligible providers, or with insufficient documentation.
CMS has conducted additional oversight activities such as provider audits, managed care plan audits, and state program integrity reviews, which have identified further overpayments.
Recommendations (4)
CMS should conduct a cost-effectiveness study to determine whether to include payments to managed care plans in recovery audits.
CMS should leverage findings from state auditors and improve collaboration to enhance oversight.
CMS should collect better data on Medicaid payments, including the source of nonfederal funding and beneficiary enrollment data across states.
Congress should consider requiring CMS to more clearly outline methods for ensuring demonstration projects are fiscally responsible.