MEDICAID MANAGED CARE: HHS Wants Fraud Guidelines
Even though Medicaid managed care plans can face much of the same fraud and abuse seen in traditional Medicaid, many lack guidelines to detect such activities, according to a recent HHS inspector general report. In a study of 10 states that have Medicaid managed care programs, most reported "limited oversight and fraud identification efforts." At the same time, the report found that many of the same activities plaguing Medicaid -- kickbacks, duplicate billing and billing for services not rendered -- occur undetected in Medicaid managed care plans. In addition, managed care plans are susceptible to enrollment fraud or undertreating members for covered medical care, the AP/Los Angeles Times reports. In calling on HCFA to "clearly define the responsibility of state agencies, managed care plans and fraud control units," the report advocates stepping up managed care detection efforts so that they are on par with those of traditional Medicaid. House Commerce Committee Chair Tom Bliley (R-VA) echoed the call, saying, "As more managed care plans provide medical services for more and more individuals who are on Medicaid, we must work with the managed care organizations and state agencies to ensure that they are fully equipped to deal with emerging fraud and abuse problems." State Medicaid agencies and the managed care plans seemed uncertain of who should fill the watchdog role, as three of the state agencies said it was not their responsibility and "some of the managed care plans said they believed that it was the state's role ... to detect potential fraud and abuse" (Srinivasan, 6/22).This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.