Earlier this month (February 2012) the HHS Office of Inspector General (OIG) released its report regarding the assessment of Review Medicaid Integrity Contractors (MICs). The OIG review looked at Review MIC assignments made between January 1 and June 30, 2010. The objectives of the study were to determine to what extent Review MICs were able to complete assignments, recommend audit leads, and identify potential fraud; and to determine what obstacles the Review MICs encountered during the review process.
CMS awarded MIC responsibility to two firms: Thompson Reuters and AdvanceMed. Assignments are given to Review MICs by CMS on a monthly basis. Each assignment specifies the state from which the claims will come, the type of claims, and a range of service dates. Once an assignment is complete, the Review MIC submits its report to CMS where it undergoes a quality assurance review. The assignment must pass this review to be considered complete.
Of the 361 assignments the Review MICs were tasked with during the OIG review period, 81% were completed and 17% were placed on hold by CMS. Rather than recommend specific audit leads as a result of their findings, CMS required the Review MICs to submit lists of providers ranked by the amounts of their potential overpayments. From these lists of 113,378 providers CMS selected 244 audit targets with a total of $39.8 million in potential overpayments from a retrospective 5-year audit period established by CMS.
The OIG review found that not only were the Review MICs unable to accurately complete assignments because of missing or inaccurate data, but states also invalidated more than one third of sampled potential overpayments. States compared the Review MIC findings with information in their state systems and found that 34% were not overpayments.
The OIG reports makes two recommendations, both of which CMS concurs with. The first is to improve the quality of data that Review MICs can access for conducting data analysis. One option the OIG provides is to facilitate Review MIC access to states’ Medicaid data systems. The CMS comments on the OIG report, in which they concur with the OIG recommendations, indicate that CMS has several initiatives underway to improve the quality of the data available to the Review MICs. One CMS long term strategy is to improve the Medicaid Statistical Information System (MSIS). MSIS is currently the only nationwide database of Medicaid claims and beneficiary eligibility information.
The second OIG recommendation is that CMS should require Review MICs to recommend specific audit leads. The OIG report suggests that these audit leads would have the best potential for recoveries and improve the value of the Review MICs contribution to the Medicaid Integrity Program. In their comments, CMS concurs with this recommendation and that the Review MIC assignments will now include specific recommendations for specific audit targets.
The full OIG report can be found on the OIG website.
Providers should be aware of Review MIC activity in their state to make sure they are prepared for any potential audit activity. If you have any questions about Review MIC activity or how to handle a MIC audit, please contact a Wachler & Associates attorney at 248-544-0888.