June 28, 2018 - Posts

With Medicaid Fraud Rampant and Increasing, CMS Announces New Initiatives to Strengthen Program Integrity

This week, the Centers for Medicare and Medicaid Services (CMS) announced a series of new programs to fight fraud, waste, and abuse within the Medicaid program. This announcement follows an April report from the Government Accountability Office (GAO), which found that improper Medicaid payments—a category that includes fraudulent claims—reached $37 billion last year.


Among the new initiatives announced this week:

  1. Medical loss ratio (MLR) audits of states based on the amount spent on clinical services and quality improvement versus administration and profit;
  2. Audits of states that have been previously found to be high risk by the OIG to examine how those states determine which groups are eligible for Medicaid benefits; and
  3. Optimizing state-provided claims and provider data to ensure that CMS and the relevant oversight bodies have access to the best and most reliable data possible.


In this week’s press release, CMS Administrator Seema Verma emphasized that the agency “will use the tools we have to hold states accountable as we work with them to keep Medicaid sound and safeguarded for beneficiaries.” Of course, one other important tool to keep Medicaid sound is whistleblowers who are willing to come forward and report on Medicaid fraud.  The federal False Claims Act covers claims for fraud against Medicaid, and more than half of all states have false claims act statutes of their own.


CMS’s full press release can be found here.


To learn more about our Whistleblower & Qui Tam practice click here.  Our firm is located in Nashville, Tennessee but we represent whistleblowers all around the country.

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