Data access key to fighting Medicaid fraud, GAO finds

Data access key to fighting Medicaid fraud, GAO finds

The Centers for Medicare and Medicaid Services need to get better at managing and monitoring their data, a recent Government Accountability Office report suggests.

In a recent analysis of beneficiary and provider data from four states, GAO found that some  8,600 beneficiaries had received payments from two or more of the four states, identities of 200 deceased people were used to apply for Medicaid benefits after death, and about 50 providers who were excluded from Medicaid for patient abuse, fraud, theft or bribery were still receiving reimbursements.

GAO investigated Medicaid claims from 2011, the most recent and reliable data in the four states -- Arizona, Florida, Michigan, and New Jersey --  that accounted for 13 percent of all fiscal year 2011 Medicaid payments.

Medicaid is a hugely complex systems with millions of beneficiaries and providers, Seto Bagdoyan, director for audit services in GAO’s Forensic Audits and Investigative

Service team, said in a GAO WatchBlog podcast. “Something of this scope and scale is inherently vulnerable to fraud and improper payments and other untoward activity,” Bagdoyan acknowledged. But with the expected growth of Medicaid, he said, it’s important that controls are in place to promote program integrity and prevent fraud.

Increasing data-sharing between the federal government and state Medicaid programs could help enhance efforts to identify improper payments and potentially fraudulent activities, GAO found.

The watchdog agency recommended that CMS provide additional guidance on accessing information in federal databases to better identify beneficiaries who are deceased. Additionally, CMS should give states guidance on the availability of automated information through Medicare’s enrollment database -- the Provider Enrollment, Chain and Ownership System -- to help screen Medicaid providers more efficiently and effectively.

According to Bagdoyan, helping states to better utilize these databases and improving their access to these sets is a major part of addressing the problem. “It is a reasonably assured standard that they'll do everything they can to promote program integrity and catch as much potential fraud per payment as they can,” said Bagdoyan.

Full report:

About the Author

Amanda Ziadeh is a former reporter/producer for GCN.


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