Medicaid: Expect more scrutiny

Several factors are contributing to an uptick in audits, say consultants
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Friday, April 12, 2019

YARMOUTH, Maine – With the Office of Inspector General and other government agencies regularly issuing reports on Medicaid overpayment issues, it’s no surprise that audits are increasing, says Kelly Grahovac.

An OIG report released in March found that Medicaid Fraud Control Units recovered nearly $14.9 million against DMEPOS suppliers in 2018.

“We have seen an uptick in audits,” said Grahovac, senior consultant for The van Halem Group. “I think there’s just more pressure across the board in the states now that the OIG has continued to highlight these overpayment issues.”

Also kicking audits up a notch: In June 2018, CMS announced new Medicaid program integrity initiatives to address fraud and improper payments, like using analytics to improve eligibility and payment data.

In March, MassHealth, the Massachusetts Medicaid program, announced it would audit all suppliers after an April 2017 report found that $206,000 in improper payments were made on a variety of claims.

“The MassHealth audit isn’t a result of a large dollar amount identified, but because they had their own internal systems issues,” said Grahovac. “It’s sort of a like a check (on their systems). Thinking in those terms, it opens suppliers up to audit for any reason.”

Other states that have seen an uptick in Medicaid audits include Texas, New York and Connecticut, said Grahovac.

“If a supplier bills their state’s Medicaid program, I would definitely encourage them to be prepared for additional audit scrutiny,” she said. “You really need to review those policies and prep yourself. Monitor and audit your own claims.”