On Feb. 25, Centene offered CMS seven Medicaid reforms that would allow managed care organizations to take the reins in targeting fraud, waste and abuse in Medicaid.
The letter called on CMS to:
1. Permit proactive payment suspensions without a waiting period for government approval
2. Broaden prepayment review capabilities
3. Standardize program integrity requirements across the country
4. Require data-sharing among MCOs, state agencies and law enforcement
5. Allow a time-limited exception to prompt-pay requirements amid active claim investigations, as well as a short-term waiver of network-adequacy requirements when an MCO needs to replace a provider who committed fraud
6. Let MCOs use statistically valid sampling and extrapolation for audits to boost efficiency
7. Prompt MCOs to advance preventive anti-fraud measures, allowing expenses to be in the medical loss ratio numerator across all government-sponsored health programs
“The efforts of managed care organizations like Centene to combat [fraud, waste and abuse] are hindered by a complex web of regulations,” the letter said. “Specifically, restrictive procedures impede swift corrective action, non-standardized requirements divert investigative resources to administrative tasks and outdated expense-reporting rules discourage investment in anti-fraud measures.”
Centene’s letter follows CMS announcing its own efforts to crack down on Medicaid fraud. The agency froze $260 million in federal Medicaid funding to Minnesota, pointing to unsupported or potentially fraudulent claims. Gov. Tim Walz described the move as part of “a campaign of retribution” against blue states.
CMS also imposed a six-month nationwide moratorium on new Medicare enrollment for some durable medical equipment suppliers. CMS is seeking comment on its “Comprehensive Regulations to Uncover Suspicious Healthcare” initiative, as well.
