Data Shortfalls Hamper Medicaid's Oversight Ability, GAO Finds

CMS has touted an upgraded reporting system to spot overpayments, but only 18 states have implemented it so far.

Giving states increased latitude over how they operate Medicaid gives them the ability to tailor programs to local needs, but this also makes it harder for CMS to spot problems that can lead to improper payments, according to a new report from the Government Accountability Office (GAO).

Lack of uniform data—something CMS has acknowledged—is a major barrier to good oversight, one that the report found must be addressed sooner rather than later. In particular, CMS has pinned its oversight hopes on the Transformed Medicaid Statistical Information System (T-MSIS). As of October, only 18 states were taking part; however, these accounted for 70% of the Medicaid population, according to the report.

The report released Monday comes as Congress wants to rethink Medicaid expansion under the Affordable Care Act (ACA), a law that has vastly expanded the Medicaid population and, at the same time, given states increased flexibility through waiver programs to customize Medicaid to state needs. Congress will likely weigh whether Medicaid should be run as a block grant program, a change that would only increase the lack of uniformity among state programs.

GAO found that in 2015, Medicaid accounted for $347.5 billion in federal spending and $206.8 billion in state matching funds. GAO estimated that improper spending reached $36.3 billion in Medcaid in 2016, up from $14.4 billion in 2013, the year before expansion took full effect. That’s not to say that CMS is not cracking down on fraud; it is, and it used data modeling to do so.

Still, the GAO found:

  • Current expenditure data do not accurately describe how states finance their Medicaid share, making it harder for CMS to evaluate appropriateness.
  • Available utilization data are incomplete and may be reported up to 3 years late. This is especially true in managed care, which accounts for an ever-increasing share of the program.

GAO sees value in the T-MSIS improvements—it just wants to see them implemented at a quicker pace. Under T-MSIS, states make the following reporting changes:

  • Data are reported monthly, not quarterly.
  • The number of data variables rises from 200 to 550.
  • The system implements 3500 quality checks to catch bad data.

This was the second GAO report in a week to examine how well Medicaid is doing at making sure only those eligible for the program get benefits, at bolstering oversight of Medicaid managed care, at making sure providers are eligible to take part in the program, and at making sure Medicaid and the healthcare exchanges are coordinating to make sure people cannot get duplicate coverage. In a January 31, 2017, report, GAO found that CMS was taking steps to improve oversight, but not a pace that would catch enough overpayment and fraud, given the growth of the system. For starters, CMS needs better coordination with states, the report found.

“States, which are responsible for the day-to-day administration of the Medicaid program, are the first line of defense against improper payments,” the report said.

When it comes to double coverage, the investigators wrote, “CMS has conducted checks to identify individuals with duplicate coverage, and plans to complete these checks at least 2 times per coverage year, which has the potential to save federal—as well as beneficiary—dollars. However, CMS has not developed a plan for assessing whether the checks and other procedures—such as thresholds for the level of duplicate coverage deemed acceptable—are sufficient to prevent and detect duplicate coverage.”