So, why is there such a paucity of accurate information? Most of the blame can be traced to the decentralized nature of the Medicaid program. Medicaid, as a federal-state partnership, relies to a great degree on information from the 50 state-Medicaid programs throughout the country. The GAO has noted that data from some states are reported years late, and others have failed to report complete data.
Recently, CMS implemented a national repository for Medicaid data – the Transformed Medicaid Statistical Information System (T-MSIS). While implementing the T-MSIS initiative is a multi-year process, CMS has apparently already seen improvement in the frequency of data reported by the various states, and in the timeliness of reporting.
That said, several states were still not reporting all of the required data through the T-MSIS. In addition, different states tended to format the T-MSIS data differently, making it more difficult for CMS to be able to do cross-state comparisons.
According to the GAO, CMS to date has not conducted a full fraud risk assessment for Medicaid, and has not designed a risk-based antifraud strategy. Without those components, CMS is less able to ferret out the kinds of fraud that cost the Medicaid millions, or even billions of dollars. With a proper fraud risk assessment, CMS would be able to identify risks, estimate likelihood of fraud, and judge the potential impact of such fraud. GAO has determined that with proper assessment, CMS could better ensure that it was addressing all of the possible risks, and properly prioritize those fraud risks that are the most significant.
While CMS is the centralized federal agency that oversees the Medicaid program, more collaboration with the states would improve oversight considerably. Indeed, state auditors have conducted evaluations that identified significant improper payments and outlined deficiencies in Medicaid processes. For example, an Oregon audit found about 31,000 questionable payments to Coordinated Care Organizations and found that about 48,000 people enrolled in Oregon’s Medicaid program were ineligible. That finding equated to about $88 million in avoidable expenditures. As another example, Massachusetts identified more than $211 million in unallowable, questionable, duplicative, unauthorized, or potentially fraudulent billing in its state program.