OIG issued a new report finding that in 2022 some Medicaid managed care plans self-reported making no or very few potential provider fraud, waste, and abuse referrals. OIG reported that 33 plans, ten percent of those reporting, did not make any referrals of potential provider fraud, waste, or abuse. The report also found that a majority of Medicaid managed care plans made two or fewer provider referrals per 10,000 enrollees and 8% of plans were unable to report the number of referrals that they made. Only 11% of plans made 10 or more referrals per 10,000 enrollees. OIG conducted the study using a survey of eligible plans and 337 of 388 eligible plans responded to the survey.
OIG found that the Medicaid managed care plans that received State or MFCU training on the fraud referral process were more likely to make referrals and that the plans that had staff dedicated to one Medicaid managed care plan made more referrals than those who had staff working across plans. Notably, only about half of the Medicaid managed care plans participating in the survey reported receiving fraud referral process training and 78% of participating plans reported having staff that were working across programs instead of being dedicated to a Medicaid managed care plan.
Based on its report, OIG recommends that CMS: (1) follow up with the 21 states that had plans that made no referrals or were unable to report referrals in 2022, and (2) encourage states to ensure more plans receive training on the fraud referral process. CMS stated that it has and will continue to reach out to states with plans that had no referrals or that could not report the number of referrals. CMS also agreed with OIG’s second recommendation to encourage more training. CMS indicated that it plans to follow up through UPIC audits.
When asked about how to improve referrals, over half of the plans reported that having a nationwide process for making referrals would be helpful. Many plans also expressed interest in having a nationwide referral template to make the referral process easier.
The report highlights OIG’s continued focus on Medicaid managed care fraud and abuse with Medicaid managed care accounting for the majority of Medicaid spending. Medicaid managed care is also the primary vehicle for Medicaid care delivery and likely a continued target of enforcement. Medicaid managed care plans are required to refer potential provider fraud, waste and abuse concerns to the State or MFCU, but there are not any incentives to do so. Several recent studies have cited concerns with the low number of referrals from Medicaid managed care plans when compared with Medicaid fee-for-service programs. Medicaid managed care will likely be a continuing area of interest for state and federal fraud, waste, and abuse enforcement agencies. Providers should continue to monitor this evolving area of enforcement and continually review their Medicaid managed care compliance measures.
