Medicaid Audit Program LaunchedModeled After Medicare Anti-Fraud Effort
HHS published a final rule for the Medicaid Recovery Audit Program this week. Created under the healthcare reform legislation, the program is designed to help states identify and recover improper Medicaid payments. As in the ongoing Medicare effort, independent auditors will be paid a contingency fee out of any improper payments they recover.
HHS is projecting that the Medicaid audits of provider organizations could save as much as $2.1 billion over the next five years, of which $900 million will be returned to the states. The Medicare audit effort is on a pace to grow from recovering roughly $75 million in 2010 to nearly $670 million in 2011.
The auditors review claims after payments have been made using automated review processes and detailed reviews of medical records and other documentation.
The healthcare reform legislation, known as the Affordable Care Act, provided an additional $350 million over 10 years to ramp up anti-fraud efforts, including scrutiny of claims before they've been paid, investments in data analytics and funding for law enforcement agents and others to fight fraud. Since June 30, the Centers for Medicare & Medicaid Services has been using predictive modeling technology in an effort to prevent fraudulent payments.