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General Accounting Office Report - Medicaid Payments to Insurers for Administrating HMO Services Needs More Auditing Algorithms

Posted Aug 05 2010 12:24am

Private insurers administrate Medicaid as mentioned in the article below and GAO is recommending that CMS audit and be sure the money is not being over paid. 

It’s time for CMS to begin their own algorithmic formulas and take on those that audit medical claims for payment to consumers.  This is interesting to start to see the government and other areas of business recommending “business intelligence” methodologies to ensure the government is not being ripped off in what they pay out to administer Medicaid plans across the US.  image

The report states inadequate data is being submitted from the insurers and they want more to ensure the money is spent appropriately and that some states are not being overpaid.  BD 

Aug 4 (Reuters) - U.S. Medicaid payments to private insurers need greater oversight to ensure that rates are appropriate, according to a report from the Government Accountability Office released on Wednesday.

Medicaid, administered by the states with reimbursements from the federal government, increasingly relies on insurance companies like UnitedHealth Group Inc ( UNH.N ) and Coventry Health Care Inc ( CVH.N ) to deliver its services. In 2007 more than $62 billion was spent on managed care.

Under a managed care model, a fixed rate is charged for a set of services instead of a fee for every service.

The report recommended that CMS track rates in each state and set clearer standards for rate reviews.

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