By Donielle Tigay Stutland, J.D.
GAO report reveals that while CMS has taken steps to improve Medicaid oversight, there are still areas to be improved upon to ensure only eligible individuals enroll in the Medicaid program.
The Government Accountability Office (GAO) released a report detailing ways to improve accuracy in beneficiary enrollment in Medicaid, including closing gaps in oversight, improving data and more collaboration between states and the federal government. As the federal government and states share the financing and administering of the Medicaid program, the GAO examined Medicaid reports and recommendations between 2015 through 2018 to offer further suggestions to enhance improvements to ensure accurate beneficiary enrollment. The GAO report focused on three areas, which include: closing gaps in oversight of eligibility determinations and related expenses, improving data, and furthering federal-state collaboration. While there has been much improvement over the past few years, the GAO believes there is still room for growth and continued oversight, enhanced data and federal-state collaboration are keys to improve the Medicaid enrollment process (GAO Report, GAO-20-147T, October 30, 2019).
Oversight. The GAO had previously identified gaps in CMS overnight in Medicaid eligibility determinations. It notes that accurate eligibility determinations are imperative to ensure that state expenditures are appropriately matched with federal funds. In September 2016, the GAO reported on vulnerabilities it found in the undercover testing system with respect to determining Medicaid eligibility. In August 2018, the GAO reported oversight improvement recommendations. CMS, in November 2018, noted that it believed the sampling methodology was sufficient, and that the agency could not revise it given its resources. However, the GAO believes that action is still needed to better target areas of high risk and this recommendation remains unimplemented.
Data. According to the report, CMS has acknowledged that improved data could improve Medicaid enrollment oversight. The agency’s primary effort in this arena is the Transformed Medicaid Statistical Information System (T-MSIS). This initiative, conducted jointly with the states, should broaden the amount of data collected, and improve the quality of state reported data. The GAO has issued recommendations related to T-MSIS. While CMS has concurred with the GAO’s recommendations related to T-MSIS, there are still many recommendations to be implemented, such as including expediting the use of T-MSIS data for oversight, and outlining a plan and associated time frames for using the data for oversight.
Collaboration. The GAO still believes that oversight in the Medicaid program could be improved by better federal-state collaboration. While the report notes that the GAO has previously reported that collaborative activities between states and CMS are important to improving oversight, the GAO still believes there is more area for growth with respect to federal-state cooperation.
In particular, the GAO believes state auditors are in a unique position to help CMS in its oversight, as state auditors are in a unique position to identify improper payments, as well as other deficiencies within the system. With respect to combating Medicaid fraud, CMS has ongoing training efforts for state officials. The report notes that steps have been taken to ensure state auditors are better enabled to ensure to ensure beneficiaries qualify for the Medicaid program and are enrolled in the correct eligibility group.
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