Evidence record
Medicaid CMS Oversight and Guidance Could Improve Recovery Audit Contractor Program
- Publishing agency
- U.S. Government Accountability Office
- Publication date
- June 28, 2023
- Source record
- Original document linked
Findings
5
Recommendations
4
Overall conclusion
CMS's oversight of the Medicaid RAC program has been inconsistent, with missed opportunities to recover overpayments and improve program effectiveness. Implementing recommended policies and conducting targeted studies could enhance the program's efficiency and recovery potential.
Scope
The audit covers the Medicaid Recovery Audit Contractor (RAC) program during fiscal year 2021, including state participation status, CMS oversight practices, exemption processes, and the scope of audits, particularly focusing on the inclusion of managed care payments and the monitoring of program effectiveness.
Findings (5)
Each finding has a stable link.
- F-058
Most states did not participate in the Medicaid RAC program during fiscal year 2021, citing reasons such as having other program integrity initiatives, inability to procure a contractor, and high enrollment in managed care.
- F-059
CMS did not consistently establish or communicate expiration of exemptions for full participation, leading to potential missed opportunities for recovery.
- F-060
Most participating states operated with regulatory exceptions, which could influence program effectiveness.
- F-061
CMS's oversight was inconsistent, particularly regarding monitoring SPA expiration dates and reporting on program effectiveness.
- F-062
CMS has not conducted a cost-effectiveness study on including managed care in the RAC scope, despite the growth of managed care enrollment.
Recommendations (4)
- R-080
Establish and implement written policies and procedures to document and communicate SPA expiration dates.
Related finding F-059 - R-081
Establish and implement policies to monitor SPA expiration dates.
Related finding F-061 - R-082
Describe the effectiveness of the RAC program and include recommendations for improvement in annual reports to Congress.
Related finding F-061 - R-083
Conduct a study to determine the cost-effectiveness of including managed care payments in the RAC program.
Related finding F-062