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Medicaid Integrity Program Audits: Coming to a Hospital Near You

Andrea Kraynak, for HealthLeaders Media, July 16, 2009

Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according to CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on Wednesday.

CMS hopes to identify additional contractors by the end of the week. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:

  • Review provider actions to determine whether fraud, waste, or abuse may have occurred

  • Audit provider claims

  • Identify overpayments

  • Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries, and others with respect to payment integrity and quality of care

There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will provide education to providers and others on Medicaid payment integrity and quality of care.

CMS acknowledged on the call that it could do a better job of provider outreach, and it is taking measures to increase educational efforts, now that it has finished building the Medicaid Integrity Program organization and developing the audit process.

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