In a June 29, 2012 letter to Senators Baucus, Hatch, Grassley, Wyden, Carper, and Coburn, the National Association of Medicaid Directors (NAMD) offered recommendations on how to improve current Medicaid program integrity (PI) efforts.  NAMD explains that state Medicaid Directors are concerned “by the disjointed and ineffective approach” to Medicaid PI efforts and are “struggling to balance the maintenance of existing efforts and meeting new requirements.”  NAMD further provides that states’ concerns regarding Medicaid PI efforts are exacerbated by the fact that the Medicaid program is in a period of “historic change” and many states face ongoing budget constraints.

NAMD identifies numerous ways to improve current federal and state Medicaid PI efforts, including but not limited to the following:

• Clarify the roles of federal and state Medicaid PI responsibilities.  According to NAMD, it is not clear whether Congress intends for CMS to primarily oversee states’ PI efforts or whether CMS is to assume primary responsibility of state PI efforts.  NAMD explains that this lack of clarity has resulted in “significant duplication and inefficiency as well as confusion about information sharing and which entity is carrying out any particular activity.”   
• Provide meaningful technical assistance to strengthen state Medicaid PI activities.  NAMD recommends the expansion of the national Medicaid Integrity Institute.  NAMD further recommends that CMS develop a compendium of model state Medicaid policies and practices.
• Facilitate immediate collaboration between Medicare and Medicaid.  For example, NAMD recommends, among other things, that states be authorized to access the Medicare fraud investigation database, have real-time access to the federal Automated Provider Screening System, and establish a federal Medicare PI liaison for each state Medicaid program.  While NAMD encourages collaboration between Medicaid and Medicaid, NAMD also cautions that “it is generally not effective or operationally feasible to retrofit a Medicare-designed initiative to the Medicaid program.”
• Establish a national PI entity to improve ongoing collaboration.  NAMD recommends the establishment of a national PI entity that could be tasked to develop mechanisms to increase ongoing collaboration between Medicare and Medicaid.
• Ensure that federal programs reflect the unique aspects of the Medicare and Medicaid programs.  NAMD emphasizes that a “one-size-fits-all” approach to Medicaid PI is not appropriate given the unique design of each state Medicaid program.
• Improve Collaboration between Medicaid and DHHS OIG.   According to the NAMD, state Medicaid Directors seek to work more collaboratively with the Department of Health and Human Services Office of the Inspector General (DHHS OIG) to identify potential investigation targets.  NAMD believes such collaboration is necessary in order to “address current concerns with methodologies that lead to overstated overpayments.”

NAMD also specifically addresses the perceived inefficiencies of the federal Medicaid Integrity Contractor (MIC) program.  NAMD provides that “problems plaguing the Audit MIC program” include insufficient coordination with the states and inaccurate data.  To that end, NAMD recommends that CMS “undertake a thorough [state-by-state] evaluation” of the return on investment (ROI) of the Audit MIC program and eliminate the Audit MIC program if it does not demonstrate a “reasonable ROI for federal and state partners.”  NAMD is also concerned that the implementation of the Medicaid Recovery Audit Contractor (RAC) program will overlap with existing MIC reviews.  Finally, NAMD requests that CMS “redirect the focus and resources of the Medicaid Integrity Group (MIG) away from conducting Medicaid integrity reviews.” 

To view all of the NAMD’s recommendations, click here.

Reporters, Sara Kay Wheeler, Atlanta, +1 404 572 4685, skwheeler@kslaw.com and Stephanie F. Johnson, Atlanta, +1 404 572 4629, sfjohnson@kslaw.com.