Medicaid Directors Urge CMS To Revamp Program Integrity Efforts To Reflect Managed Care Focus

As more Medicaid beneficiaries are enrolled in managed care plans, the National Association of Medicaid Directors is urging CMS to focus on four overarching program-integrity areas: provider enrollment; data reporting; compliance; and benefits' coordination. Streamlining processes and offering guidance to states in these areas requires the agency to work closely with state Medicaid programs and highlight some of the most innovative and efficient state practices, NAMD says in a letter to CMS.

"As states work to enhance their policies and tools to safeguard the program, we believe CMS also must do more to keep pace with the evolving delivery model and new tools used in the managed care environment. Doing so requires ongoing partnership with states to ensure Medicaid agencies can design and administer a program that aligns with the state structures, capacity, resources and program integrity goals," NAMD writes in its letter dated Sept. 2.

NAMD says CMS designs program-integrity policies primarily for fee-for-service providers, but as risk-based managed care programs become the norm in Medicaid, "(p)olicies and tools must be designed to look within and across managed care entities and health care programs."

In the area of provider enrollment NAMD says CMS needs to centralize provider screening databases into one central portal. It is the same suggestion the organization made to Senate Finance Chair Ron Wyden (D-OR) and committee member Charles Grassley (R-IA) in response to the lawmakers' call for input on how to increase transparency in Medicaid. NAMD points out that states have to use a number of disparate databases and processes -- including the List of Excluded Individuals, Provider Enrollment, Chain and Ownership System, and the Excluded Parties List Search -- to screen and enroll providers. The organization encourages CMS to continue work to develop its OnePI portal with this goal in mind, and suggests the agency also study the feasibility of creating a database that provides information on civil and criminal actions states and the federal government have taken against managed care entities.

NAMD would like CMS to align Medicare and Medicaid provider enrollment policies where possible to help states better serve their dual eligible populations.

"In several instances there are discrepancies or gaps in CMS policies that impact the integrity of Medicaid provider enrollment processes and create confusion as it relates to providers who care for dually eligible individuals. In others, enhancing information sharing across programs would streamline enrollment processes," NAMD writes.

The organization also would like CMS to put together technical research tools for states that show model state practices in streamlining provider enrollment.

In the area of data and reporting, NAMD suggests that CMS align its guidance with sophisticated state models for encounter data collection and validation approaches. The organization says that while states' Medicaid programs "are leveraging and building on existing national standards for encounter and claims data to the greatest extent possible," they are finding that the agency's standards and expectations are not aligned across various Medicaid transactions.

"Specifically, transformed MSIS (TMSIS) submissions are inconsistent with the type of data that CMS is seeking through standard encounters and claims reporting structures and other transactions that impact program integrity initiatives. This makes it difficult for states to align their own reporting requirements for risk-bearing entities and subsequently to provide CMS with the information it seeks," NAMD writes.

NAMD suggests that CMS work with other HHS agencies to audit how data collection efforts and requirements align with HHS research and policy objectives in order avoid operational inefficiencies and confusion.

As it also said in its letter to Wyden and Grassley, NAMD again calls on CMS to work with states when analyzing state-specific data.

"State experts are best positioned to identify these issues for our federal partners so that they may conduct accurate analyses of an individual state's data and the Medicaid program generally. An improved communication process between CMS officials and state data experts would positively impact that state's data interpretation and analysis," NAMD writes.

In the area of compliance staffing requirements NAMD is asking CMS to mandate that all Medicaid managed care entities submit annual fraud, waste and abuse plans to states. The organization says CMS should develop minimum requirements for the fraud, waste and abuse plans but give states discretion on how they enforce those standards. States should be allowed to establish their own minimum requirements for compliance officers within managed care entities -- which can include requirements for certain certifications or other professional criteria and staffing levels within an entities compliance unit.

"This will help ensure that these units are appropriately staffed to ensure compliance with policy and contracts and to interpret regulations and statutory provisions that are a critical component of PI activities. In addition, states may wish to require that plans have a Special Investigations staff which focuses on or is specifically dedicated to the entity's Medicaid line of business," NAMD writes.

In the area of coordination of benefits, NAMD asks that CMS develop a uniform minimum standard for the coordination of benefits "in order to ensure that Medicaid remains the payer of last resort." The organization says CMS should require states to keep centralized lists of Medicaid clients who are also confirmed to have private insurance coverage and make these lists available to Medicaid managed care organizations. The agency should also approve approaches for states to require Medicaid managed care organizations to document coordination of benefits activities to make sure other insurers were billed before Medicaid claims have been made, NAMD says. -- Todd Allen Wilson (twilson@iwpnews.com)