OIG recommends increased focus on Medicaid managed care

WASHINGTON – The U.S. Office of Inspector General recommends that CMS implement a plan to increase Medicaid program integrity activities by the UPICs.

The OIG found that UPICs conducted substantially more program integrity work for Medicare FFS than Medicaid in 2019. It also found they conducted only minimal activities related to Medicaid managed care, even though most Medicaid enrollees receive services through managed care. Additionally, the OIG found that UPICs reported no data analysis projects related to Medicaid managed care and they reported only one fraud referral for Medicaid managed care.

“Overall, UPICs conducted disproportionately fewer Medicaid activities compared to the levels of funding they received from CMS for Medicaid program integrity activities,” the OIG stated.

The OIG acknowledged that the UPICs faced several challenges that could have contributed to the lower levels of activity in Medicaid, including problems with data availability and quality, and differences across state policies and regulations.

At the same time, the OIG found CMS and the UPICs have laid a foundation for improvements, including the development of collaborative processes, analytical codes and new technologies across the UPICs, like the United Case Management system and Major Case Coordination initiative.

The OIG recommends CMS make improvements to the UCM system, implement a plan to help ensure the success of MCC for Medicaid referrals and identify the reasons for the unexplained variation in program integrity activities across UPICs. CMS concurred with all recommendations.