Absence of Reliable Data Hinders Effort to Curb Medicare, Medicaid Fraud

Absence of Reliable Data Hinders Effort to Curb Medicare, Medicaid Fraud

By Emily Ethridge, CQ Staff

A lack of reliable data from states is impeding the government’s efforts to improve prevention and detection of waste, fraud and abuse in Medicare and Medicaid, witnesses told a House subcommittee hearing Thursday.

Although the Centers for Medicare and Medicaid Services (CMS) has made improvements in monitoring Medicare for fraud and abuse, the agency still has far to go when it comes to Medicaid — and both programs remain vulnerable.

Edolphus Towns of New York, ranking Democrat of the House Oversight and Government Reform Subcommittee on Government Organization, said that improper Medicare payments were estimated to be at nearly $43 billion in 2011, and $21.9 billion for Medicaid.

But problems with Medicaid have prevented some of CMS’s auditing programs from successfully identifying overpayments and abuse, according to witnesses from the Government Accountability Office and the Department of Health and Human Services’ Office of Inspector General (OIG).

Not only does each state have its own distinct Medicaid program, with varying rules that can confuse contractors, but states often provide inaccurate data to federal overseers.

“National Medicaid data are not current, they are not complete, and they are not accurate,” said Ann Maxwell, a regional inspector general at OIG. “We absolutely need national standardized Medicaid data to make these programs worthwhile.”

That lack of reliable data affects not only the National Medicaid Audit Program, but also the Medicare-Medicaid Data Match program, designed to help state and federal agencies analyze billing trends in both programs to identify potential fraud.

Maxwell said both audit programs have had a negative return on investments — returning less money to states and taxpayers than they spent trying to track down the fraud and abuse.

“Only limited results are trickling out,” she said.

Rep. James Lankford, R-Okla., questioned why $60 million was spent on the Medicare-Medicaid Data Match program, when it recouped only $58 million.

“That doesn’t seem like a great investment in the program,” he said.

Rep. Michele Bachmann, R-Minn., questioned why Medicaid data had not yet been added to CMS’s One Program Integrity System (One PI), a program meant to merge Medicare and Medicaid data. Since 2006, CMS has spent more than $100 million developing the system.

Although the collected Medicare data is largely reliable, the quality of the Medicaid data is far from matching it, said Peter Budetti, deputy administrator and director for the Center for Program Integrity at CMS.

He added that CMS does not expect the matching Medicaid data to be fully included in the system’s data repository until 2014.

“There is a complete lack of reporting, collection and verification of meaningful data in Medicaid. The same is not true of Medicare,” Bachmann said. She also announced plans to introduce a bill this month that would “hold CMS accountable” to ensure that audits of state data are conducted properly.

Subcommittee Chairman Todd R. Platts, R-Pa., questioned what CMS is doing now, when it doesn’t anticipate being able to use the Medicaid data in the One PI system until 2014.

“We can’t just sit and wait for those data to be available,” Budetti said. He noted that CMS is currently conducting a demonstration program with 10 states to help identify the pieces of information it needs, to help develop a new model for Medicaid data collection.

States actually have much more complete Medicaid data than they have been sharing with the federal government, he said, so CMS is now collaborating directly with the states.

Budetti hopes that engagement will help “so we’re not just dependent on the data that flow to us.”

In general, Budetti said Medicare oversight programs are “in good shape” and have adequate technologies and systems to conduct strong audits, but that CMS needs to “translate that advancement to the Medicaid side.”