Further Action Needed to Address Vulnerabilities in Medicaid and Medicare Programs

GAO-12-803T, Jun 7, 2012.

For the Medicaid program, the Centers for Medicare & Medicaid Services (CMS) and the states have taken some actions related to GAO’s four key strategies but more needs to be done.

  • CMS’s comprehensive state program integrity reviews identified provider enrollment as the most frequently cited area of concern but the agency has noted a positive trend in states’ awareness of regulatory requirements.
  • CMS noted vulnerabilities in the prepayment reviews of claims in five states and effective practices in seven others. In anticipation of new analytic tools to predict vulnerabilities before claims are paid, the agency has initiated discussions with and provided guidance to states.
  • CMS has begun collaborating with states to identify targets for federal postpayment audits, which should help to avoid duplication of federal and state audit efforts.
  • CMS has not established a robust process for states to evaluate and address vulnerabilities identified by the states’ new recovery audit contractors brought in to identify improper payments and recoup overpayments.

For the Medicare program, CMS has acted to strengthen several of its strategies to better ensure program integrity, but other actions remain undone. Read more