State Medicaid directors are told to develop strategies to ensure providers are legitimate. Noncompliant states could face audits.
The head of the Centers for Medicare and Medicaid Services (CMS) demanded states across the nation take action to crack down on fraud in Medicaid, one of the federal government’s health insurance programs.
In letters to state Medicaid directors, CMS Administrator Dr. Mehmet Oz said that they should develop and file with his agency a comprehensive strategy to ensure Medicaid providers are legitimate.
“Corrupt individuals and organizations masquerading as health care providers are defrauding Medicaid, and American taxpayers, of billions of dollars each year, placing valuable resources out of reach for those the program was intended to serve: low-income senior citizens, children, and disabled individuals,” Oz wrote.
Oz had recently previewed the effort, saying it would involve proving whether the providers “actually exist.”
“I love Medicaid, I cannot say that more fervently,” Oz said at a summit held by Politico. “If you love something, you protect it. You don’t let it get defrauded. You don’t let it get taken advantage of.”
If states do not take action, then audits may be an option, he said.
CMS has been investigating Medicaid and Medicare, and officials have said they have identified billions in fraudulent or potentially fraudulent spending, leading to actions such as deferring $259 million in payments to Minnesota. They have had to clarify some claims, including acknowledging an error in calculations regarding New York.
The new letters said CMS is acting under its responsibilities outlined in federal law, including the Social Security Act, and that CMS understands states face challenges administering the complex Medicaid program. They said that CMS analyses are suggesting “a persistent and growing Medicaid threat posed by sophisticated actors knowingly exploiting these complex systems for financial gains.”
“A foundational element of Medicaid program integrity is ensuring that only legitimate, qualified providers are enrolled and participating in the program,” Oz said. “Confirming that each state maintains accurate and regularly updated provider enrollment information is a critical foundation of CMS’ efforts to safeguard Medicaid program integrity, as it supports effective screening, monitoring, and oversight of participating providers.”
