By Rose Clifford, editor
© 2009 The Medical-Legal News
Medicaid Program Integrity (MPI) efforts and audits have not received as much attention as other Centers for Medicare and Medicaid Services (CMS) program integrity initiatives such as the Recovery Audit Contractor reviews (RACs), Medicare Administrative Contractors conversions, the new quality related contracts or revised scope of work statements, or the “One PI” initiative.
Enacted as part of the Deficit Reduction Act of 2005 (DRA) and currently in the third of an initial five-year project time frame, the MIP, the multiple components of the Medicaid Integrity Group (MIG), Medicaid Integrity Institute and the associated Medicaid Integrity Contractors (Thomson Reuters, AdvanceMed, Booz Allen Hamilton and HMS) and their reviews are starting to increase momentum and have an impact in multiple states.
The DRA requires CMS to hire contractors to conduct the following activities to counter fraud and abuse:
1) Review Medicaid providers’ actions to determine if fraud or abuse has occurred;
2) Audit claims for services;
3) Identify overpayments; and
4) Educate providers, beneficiaries and others with respect to payment integrity and quality of care issues.
Audit issues that have already been identified for review include, but are not limited to, services after date of death, duplicate claims, code definitions and short day admissions.
Physicians, pharmacies and providers will be most burdened in their efforts to research and defend themselves against the alleged potential overpayments within the defined time frame.
All Medicaid providers should be aware of the audit contractor reviewing their state.
Attorneys and clients will benefit and quickly glean important insight from professionals who are intimate with the program and have been following the MIG initiative for the last several years.