New HHS-OIG Report Criticizes MCO Identification of Medicaid Fraud and Abuse

The U.S. Department of Health and Human Services Office of the Inspector General issued a report yesterday that found that managed care organizations are not doing enough to identify Medicaid waste, fraud and abuse.  HHS-OIG undertook the review because it and “others have ongoing concerns about program integrity in Medicaid managed care.”

Reviewed survey data and interviewed selected MCOs and state officials

Using 2015 survey data and conducting interviews with officials from five selected MCOs and with officials from the same five States as those MCOs,

OIG found that MCOs “referred few cases of suspected fraud or abuse to the State in 2015, and not all MCOs used proactive data analysis-a critical tool for fraud identification.”   It also found that MCOs typically did not inform the state when they did take action against a provider and were lax in identifying and recovering monies.

It found that a number of states were trying to get MCOs to be more responsible for this area by “providing education and training and facilitating information sharing among MCOs.”

Similar to Texas findings

In essence, the review finds a similar experience to Texas hearings on MCOs held back in 2016.

The full report is below.

One Response

  • In 2016 and earlier we showed HHSC and other Medicaid agencies how to capture information at the point of care regardless of whether the beneficiary was covered by fee-for-service or an MCO. The GAO even says our approach would attack and prevent 22% of fraud, at a cost of less than 1% of the 22%

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