The MIG has taken three different approaches since establishing the NMAP—test audits, Medicaid Statistical Information System (MSIS) audits, and collaborative audits. In each approach, contractors conducted post payment audits, that is, they reviewed medical documentation and other information related to Medicaid claims that had already been paid. The key differences among the three NMAP approaches were (1) the data sources used to identify audit targets, and (2) the roles assigned to states and contractors. In June 2007, the MIG hired a contractor to conduct test audits, and it implemented MSIS audits beginning in December 2007 by hiring separate review and audit contractors for each of five geographic areas of the country. Collaborative audits were introduced in January 2010. In June 2007, the MIG hired a contractor to conduct test audits in five states. Working with the MIG and the states, the contractor audited 27 providers. States provided the initial audit targets based on their own analysis of Medicaid Management Information System (MMIS) data. MMIS are mechanized claims processing and information retrieval systems maintained by individual states, and generally reflect real-time payments and adjustments of detailed claims for each health care service provided. In some cases, states provided samples of their claims data with which to perform the audits, and in other cases states provided a universe of paid claims that the MIG’s contractor analyzed to derive the sample. Twenty-seven test audits were conducted on hospitals, physicians, dentists, home health agencies, medical transport vendors, and durable medical equipment providers. In December 2007, while test audits were still under way, the MIG began hiring review and audit contractors to implement MSIS audits.audits differed from the test audits in three ways. First, MSIS audit targets were selected based on the analysis of Medicaid Statistical Information System (MSIS) data. MSIS is a national data set collected and maintained by CMS consisting of extracts from each state’s MMIS, including eligibility files and paid claims files that were intended for health care research and evaluation activities but not necessarily for auditing. As a subset of states’ more detailed MMIS data files, MSIS data do not include elements that can assist in audits, such as the explanations of benefit codes and the names of providers and beneficiaries. In addition, MSIS data are not as timely because of late state submissions and the time it takes CMS’s contractor to review and validate the data. MIG officials told us that they chose MSIS data because the data were readily available for all states and the state-based MMIS data would require a significant amount of additional work to standardize across states. (See table 1 below.) Second, MSIS audits were conducted over a wider geographic area; 44 states have had MSIS audits, compared with the small number of states selected for test audits. Third, MSIS audits use two types of contractors—review contractors to conduct data analysis and help identify audit leads, and audit contractors to conduct the audits. In the test audits, the states provided the initial audit leads. Review contractors. The MIG’s two review contractors analyze MSIS data to help identify potential audit targets in an analytic process known as data mining. The MIG issues monthly assignments to these contractors, and generally allows the contractors 60 days to complete them. For each assignment, the MIG specifies the state, type of Medicaid claims data, range of service dates, and algorithm (i.e., a specific set of logical rules or criteria used to analyze the data). The work of the review contractor is summarized in an algorithm findings report, which contains lists of providers ranked by the amount of their potential overpayment. The January through June 2010 algorithm reports reviewed by the HHS-OIG The identified 113,378 unique providers from about 1 million claims.MIG’s Division of Fraud Research & Detection oversees the technical work of the review contractors. A summary of the review contractor activities for MSIS audits is shown in figure 1. Audit contractors. The MIG’s audit contractors conduct postpayment audits of Medicaid providers. Audit leads are selected by the MIG’s Division of Field Operations, generally by looking at providers across one or more applicable algorithms to determine if they have been overpaid or demonstrated egregious billing patterns. From the hiring of audit contractors in December 2007 through February 2012, the division assigned 1,550 MSIS audits to its contractors. During an audit, the contractor may request and review copies of provider records, interview providers and office personnel, or visit provider facilities. If an overpayment is identified, the contractor drafts an audit report, which is shared with the provider and the state. Ultimately, the state is responsible for collecting any overpayments in accordance with state law and must report this information to CMS. A summary of the audit contractor activities is shown in figure 2. In June 2011, CMS released its fiscal year 2010 report to Congress, which outlined a redesign of the NMAP with an approach that closely resembled the test audits. The report described the redesign as an effort to enhance the NMAP and assist states with their program integrity priorities. CMS refers to this new approach as collaborative audits. In these collaborative audits, MIG and its contractor primarily used MMIS data and leveraged state resources and expertise to identify audit targets. In contrast, MSIS audits used separate review contractors and MSIS data to generate lists of providers with potential overpayments, and the MIG selected the specific providers to be audited. From June 2007 through February 2012, payments to the contractors for On an annual test, MSIS, and collaborative audits totaled $102 million.basis, these contractor payments account for more than 40 percent of all of the MIG’s expenditures on Medicaid program integrity activities. Contractor payments rose from $1.3 million in fiscal year 2007 and reached $33.7 million in fiscal year 2011. (See fig. 3.) The total cost of the NMAP is likely greater than $102 million because that figure does not include expenditures on the salaries of MIG staff that support the operation of the program. The MSIS audits were less effective in identifying potential overpayments than test and collaborative audits. The main reason for the difference in audit results was the use of MSIS data. According to MIG officials, they chose MSIS data because the data were readily available for all states, they are collected and maintained by CMS, and are intended for health care research and evaluation activities. However, the MSIS audits were not well coordinated with states, and duplicated and diverted resources from states’ program integrity activities. Compared with test and collaborative audits, the return on MSIS audits was significantly lower. As of February 2012, a small fraction of the 1,550 MSIS audits identified $7.4 million in potential overpayments. In contrast, 26 test audits and 6 collaborative audits together identified $12.5 million in potential overpayments (see fig. 4.) Appendix II provides details on the characteristics of MSIS audits that successfully identified overpayments. While the newer collaborative audits have not yet identified more in overpayments than MSIS audits, only 6 of the 112 collaborative audits have final audit reports (see app. III), suggesting that the total overpayment amounts identified through collaborative audits will continue to grow. In addition, the MSIS audits identified potential overpayments for much smaller amounts. Half of the MSIS audits were for potential overpayments of $16,000 or less, compared to a median of about $140,000 for test audits and $600,000 for collaborative audits. The use of MSIS data was the principal reason for the poor MSIS audit results, that is, the low amount of potential overpayments identified and the high proportion of unproductive audits. Over two-thirds (69 percent) of the 1,550 MSIS audits assigned to contractors through February 2012 were unproductive, that is, they were discontinued (625), had low or no findings (415), or were put on hold (37). (See fig. 5.) Our findings are consistent with an early assessment of the MIG’s audit contractors, which cited MSIS data issues as the top reason that MSIS audits identified a lower amount of potential overpayments. State program integrity officials, the HHS-OIG, and its audit contractors told the MIG that MSIS data would result in many false leads because the data do not contain critical audit elements, including provider identifiers; procedure, product, and service descriptions; billing information; and beneficiary and eligibility information. For example, the MIG assigned 81 MSIS audits in one state because providers appeared to be billing more than 24 hours of service in a single day. However, all of these audits were later discontinued because the underlying data were incomplete and thus misleading; the audited providers were actually large practices with multiple personnel, whose total billing in a single day legitimately exceeded 24 hours. One state official told us that when states met with the MIG staff during the roll out of the Medicaid Integrity Program, the state officials emphasized that (1) MSIS data could not be used for data mining or auditing because they were ‘stagnant,’ i.e., MSIS does not capture any adjustments that are subsequently made to a claim and (2) MMIS data were current and states would be willing to share their MMIS data with CMS. In their annual lessons-learned reports, the audit and review contractors told the MIG that the MSIS data were not timely or accurate, and recommended that the MIG help them obtain access to state MMIS data.based audits to its contractors; 78 percent of MSIS audits (1,208) were assigned after the August 2009 HHS-OIG report. Nevertheless, the MIG continued to assign MSIS- MIG officials told us that they chose MSIS data because the data were readily available for all states, they are collected and maintained by CMS, and are intended for health care research and evaluation activities. However, when considering the use of MSIS data, officials said that they were aware that the MSIS data had limitations for auditing and could produce many false leads. MIG officials also told us that collecting states’ MMIS data would have been burdensome for states and would have resulted in additional work for the review contractors because they would need to do a significant amount of work to standardize the MMIS data to address discrepancies between the states’ data sets. However, officials in 13 of the 16 states we contacted volunteered that they were willing to provide the MIG with MMIS data if asked to do so. In addition, the review contractors have had to do some work to standardize the state files within the MSIS maintained by CMS. The MIG did not effectively coordinate MSIS audits with states and as a result, the MIG duplicated state program integrity activities. Officials from several states we interviewed noted that some of the algorithms used by the review contractor were identical to or less sophisticated than the algorithms they used to identify audit leads. An official in one state told us that even after informing the contractor that its work would be duplicative, the review contractor ran the algorithm anyway. Officials in another state told us that the MIG was unresponsive to state assertions that it had a unit dedicated to reviewing a specific category of claims and the MIG was still pursuing audits for this provider type. State officials also cited general coordination challenges, including difficulty communicating with contractors. MIG officials acknowledged that poor communications resulted in the pursuit of many false leads that had not been adequately vetted by the states. In addition, representatives of a review contractor we interviewed told us that states did not always respond to requests to validate overpayments in the algorithm samples provided and the MIG may not have been aware of the lack of a state response when making audit assignments. State officials we interviewed told us that the review contractors’ lack of understanding of state policy also contributed to the identification of false leads, even though (1) the MIG required its contractors to become familiar with each state’s Medicaid program, and (2) the MIG reviewed state policies as a quality assurance step prior to assigning leads to its audit contractors. Nonetheless, one state official described how the MIG and its review and audit contractors had mistakenly identified overpayments for federally qualified health centers because they assumed that centers should receive reduced payments for an established patient on subsequent visits. In fact, centers are paid on an encounter basis, which uses the same payment rate for the first and follow-up visits. Officials in seven of the states we spoke with described the resources involved in assisting the MIG and its contractors. For example, states told us that they had assigned staff to: (1) review the algorithms used by review contractors to generate potential audit leads; (2) review lists of audit leads created by the MIG; and (3) provide information and training on state-level policies to audit contractors. One state official described how it had clinical staff rerun algorithms using the state’s data system to see if the audit targets chosen by the MIG had merit.state staff found that the MIG was pursuing a false lead, the state had to provide the MIG and its contractors with detailed explanations of why the suspect claims complied with state policies. While the state officials we spoke with did not estimate the cost of their involvement in MSIS audits, officials in some states said that participation in MSIS audits diverted staff from their regular duties. MIG officials told us they were sensitive to state burden and had attempted to minimize it. MIG’s redesigned NMAP focuses on collaborative audits, which may enhance state Medicaid program integrity activities, and it also intends to continue using MSIS data in some audits. As part of its NMAP redesign, the MIG has assigned new activities to its review contractors, but it is too early to assess their benefit. CMS has not reported to Congress key details about the changes it is making to the NMAP, including the rationale for the redesign of the program, but it plans to discuss these changes in its upcoming 2012 strategic plan. As part of its redesign, the MIG launched collaborative audits with a small number of states in early 2010 to enhance the MIG’s program and assist states with their own program integrity priorities. The MIG did not have a single approach for collaborative audits. For example, one state told us that the MIG’s audit contractor suggested that together they discuss conducting a collaborative audit with the MIG while in another state a collaborative audit was initiated by the MIG, with the audit contractor’s role limited to assistance during the audit (rather than leading it). Generally, collaborative audits allow states to augment their own program integrity audit capacity by leveraging MIG’s and its contractors’ resources. For example, officials from six of the eight states we interviewed told us the services targeted for collaborative audits were those that the state did not have sufficient resources to effectively audit on its own. In some cases, the MIG’s contractor staff conducted additional audits. In others, contractors were used to assess the medical necessity of claims when the states’ programs needed additional clinical expertise to make a determination. Officials from most of the states we interviewed agreed that the investment in collaborative audits was worthwhile but some told us that collaborative audits created some additional work for states. For example, two state programs reported that their staff was involved in training the MIG’s contractor staff. In one of these states, state program staff dedicated a full week to train the MIG’s audit contractor so that the contractor’s work would be in accordance with state policies. Another state program official reported that staff had to review all audits and overpayment recovery work, leading to a “bottleneck” in the state’s own program integrity activities. Officials in one state suggested that the collaborative audits could be improved if the MIG formalized a process for communicating and resolving disagreements related to audit reports, and minimized the changing of contractors in order to reduce the burden on states. Most states were in favor of expanding the number of collaborative audits. According to the MIG, the agency plans to expand its use of collaborative audits to as many states as are willing to participate. In fact, officials indicated that they are discussing collaborative audits with an additional 12 states. MIG officials noted that they do not foresee the collaborative audits completely replacing audits based on MSIS data. According to MIG officials, NMAP audits using MSIS data might be appropriate in certain situations, including audits of state-owned and operated facilities and states that are not willing to collaborate, as part of the MIG’s oversight responsibilities. The MIG recognizes that MSIS-based audits are hampered by deficiencies in the data, and noted that CMS has initiatives under way to address these deficiencies through the Medicaid and CHIP Business Information and Solutions Council (MACBIS). MACBIS is an internal CMS governance body responsible for data planning, ongoing projects, and information product development. According to MIG officials, MACBIS projects include efforts to reduce the time from state submission of MSIS data to the availability of these data; automation of program data; improvements in encounter data reporting; and automation, standardization, and other improvements in MSIS data submissions. One MACBIS project is known as Transformed MSIS (T-MSIS), which aims to add 1,000 additional variables to MSIS for monitoring program integrity and include more regular MMIS updates. MIG officials told us that CMS is currently engaged in a 10-state pilot to develop the data set for T-MSIS, and anticipates that T-MSIS will be operational in 2014. As part of its NMAP redesign, the MIG has assigned new activities to the review contractors. Because these activities are new, it is too early to assess their benefit. Although the review contractors were not involved in early collaborative audits, the MIG expects that they will be involved in future collaborative audits based on these new activities. In redesigning the NMAP, the MIG tasked its review contractors in November 2011 with using MSIS data to compare state expenditures for a specific service to the national average expenditure for that service to identify states with abnormally high expenditures. Once a state (or states) with high expenditures is identified, then discussions are held with the states about their knowledge of these aberrations and recovery activities related to the identified expenditures. According to MIG officials, such cross-state analyses were recently initiated and thus have not yet identified any potential audit targets. The review contractor also indicated that it would continue to explore other analytic approaches to identify causes of aberrant state expenditures. Additionally, as part of its redesign of the program’s audits, the MIG instructed its review contractors in November 2011 to reexamine successful algorithms from previously issued final algorithm reports. According to the MIG, the purpose of this effort is to identify the factors that could better predict promising audit targets and thereby improve audit target selection in the future. Although some MSIS audits identified potential overpayments, the value of developing a process using MSIS data to improve audit target selection in the future is questionable.According to the MIG, MSIS audits are continuing but on a more limited scale and with closer collaboration between states and the MIG’s contractors. In its 2010 annual report to Congress on the Medicaid Integrity Program, CMS announced that it was redesigning the NMAP in an effort to enhance MIG programs and assist states with their program integrity priorities, but it did not provide key details regarding the changes. For example, the report did not mention that the MSIS audits had a poor return on investment, the number of unproductive audits, or the reasons for the unproductive audits. Moreover, since issuing its 2010 annual report, CMS has assigned new tasks to its review contractors such as reexamining old final algorithm reports to improve provider target selection and new cross-state analyses using MSIS data. But CMS has not yet articulated for Congress how these activities complement the redesign or how such activities will be used to identify overpayments. The MIG is preparing a new strategic plan—its Comprehensive Medicaid Integrity Plan covering Fiscal Years 2013 through 2017—which it plans to submit to Congress in the summer of 2012. According to MIG officials, the new strategic plan will generally describe shortcomings in the NMAP’s original design and how the redesign will address those shortcomings. However, MIG officials told us that they do not plan to discuss the effectiveness of the use of funds for MSIS audits, or explain how the MIG will monitor and evaluate the redesign. In its fiscal year 2013 HHS budget justification for CMS, the department indicated that in the future CMS would not report separately on the NMAP return on investment. HHS explained that it had become apparent that the ability to identify overpayments is not, and should not be, limited to the activities of the Medicaid integrity contractors. Rather, HHS said it is considering new measures that better reflect the resources invested through the Medicaid Integrity Program. Federal internal control standards provide that effective program plans are to clearly define needs, tie activities to organizational objectives and goals, and include a framework for evaluation and monitoring. Based on these standards, the poor performance of the MSIS audits should have triggered an evaluation of the program, particularly given the DRA requirement for CMS to report annually to Congress on the effectiveness of the use of funds appropriated for the Medicaid Integrity Program. In approximately 5 years of implementation, the MIG has spent at least $102 million on contractors for an audit program that has identified less than $20 million in potential overpayments. Moreover, almost two-thirds of these potential overpayments were identified in a small number of test and collaborative audits that used different data and took a different approach to identifying audit targets than the MSIS audits, which comprised the vast majority of the program’s audits. The poor performance of the MSIS audits can largely be traced to the MIG’s decision to use MSIS data to generate audit leads, although evidence showed that (1) these data were inappropriate for auditing, and (2) alternative data sources were both available and effective in identifying potential overpayments. Ineffective coordination with states and a limited understanding of state Medicaid policies on the part of the MIG’s contractors also contributed to the poor results of the MSIS audits. Although the MIG recognizes that the MSIS audits have performed far below expectations, it has not quantified how expenditures to date have compared with identified recoveries. Currently, the MIG is experimenting with a promising approach in which the states identify appropriate targets, provide the more complete MMIS data, and actively participate in the audits. This collaborative audit approach has identified $4.4 million in potential overpayments and is largely supported by the states we spoke with, even though they may have to invest their own resources in these audits. However, the MIG has not articulated how its redesign will address flaws in NMAP and it also plans to continue using MSIS data, despite their past experience with these data, for cross-state analysis and for states that are not willing to participate in collaborative audits. At this time, the MIG is preparing a new comprehensive plan for Congress that outlines the components of the NMAP redesign. The details provided in such a plan will be critical to evaluating the effectiveness of the redesign and the agency’s long-term plan to improve the data necessary to conduct successful audits. Transparent communications and a well- articulated strategy to monitor and continuously improve NMAP are essential components of any plan seeking to demonstrate that the MIG can effectively manage the program. To effectively redirect the NMAP toward more productive outcomes and to improve reporting under the DRA, the CMS Administrator should ensure that the MIG’s planned update of its comprehensive plan (1) quantifies the NMAP’s expenditures and audit outcomes; (2) addresses any program improvements; and (3) outlines plans for effectively monitoring the NMAP program, including how to validate and use any lessons learned or feedback from the states to continuously improve the audits; future annual reports to Congress clearly address the strengths and weaknesses of the audit program and its effectiveness; and use of NMAP contractors supports and expands states’ own program integrity audits, engages additional states that are willing to participate in collaborative audits, and explicitly considers state burden when conducting audit activities. We provided a draft of this report to HHS for comment. In its written comments, HHS stated that we had not appropriately recognized the progress CMS has made in evaluating and improving the Medicaid Integrity Program, which included the agency’s redesign of NMAP. Collaborative audits were the core of that redesign. HHS described CMS’s redesign approach as a phased one in which not all elements had been finalized when the agency announced the redesign in its June 2011 annual report to Congress (covering fiscal year 2010). HHS also commented that we did not fully describe the reasons for CMS’s use of MSIS data. HHS partially concurred with our first recommendation and fully concurred with the other two recommendations. HHS’s comments are reproduced in appendix IV. Although we characterized collaborative audits as a promising new approach, HHS commented that we (1) did not acknowledge that CMS had presented its rationale for the NMAP redesign in the agency’s June 2011 annual report to the Congress, and (2) inappropriately criticized CMS for not including other redesign details in its report, which HHS said had not yet been finalized. We continue to believe that a full articulation of the redesign should include transparent reporting of the results of the MSIS audits. However, we agree that the June 2011 report, which was released 18 months after the initiation of collaborative audits, described their advantages—use of better data, augmenting state resources, and providing analytic support for states lacking that capability. Regarding the use of MSIS data, HHS stated that we do not fully describe CMS’s reason for its use or acknowledge that CMS sought alternative data sources to supplement or replace MSIS data. We disagree because our report provides CMS’s reasons for using MSIS data, acknowledges CMS’s awareness of the MSIS data limitations, and discusses its Transformed MSIS project to improve the quality of MSIS data. In addition, we pointed out that officials in 13 of the 16 states we contacted volunteered that they were willing to provide CMS with their own more complete and timely MMIS data. We agree with HHS’s comment that not all of CMS’s plans for the redesign may have been complete at the time the June 2011 annual report to Congress was being finalized and therefore could not have been included in that report. We have revised this report to acknowledge that some of the elements of the redesign may not have been initiated until after the June 2011 report was finalized. HHS agreed with two of three elements related to our first recommendation regarding CMS’s planned update of its Comprehensive Medicaid Integrity Plan covering fiscal years 2013 to 2017. HHS agreed that the planned update should (1) address any NMAP improvements proposed by CMS, and (2) outline CMS’s plans for effectively monitoring the NMAP. HHS commented that CMS considers transparency of the program’s performance to be a top priority. However, HHS did not concur that the update should quantify NMAP’s expenditures and audit outcomes; CMS considers such information to be more appropriately presented in the annual reports to Congress, which already includes dollar figures on annual expenditures for NMAP and overpayments identified in each fiscal year. CMS’s annual reports to Congress have provided a snapshot of results that did not differentiate between the effectiveness of the various audit approaches used. For example, in its annual report covering fiscal year 2010, CMS reported that 947 audits were underway in 45 states and that its contractors had identified cumulative potential overpayments of about $10.7 million. Based on our analysis of CMS’s data, MSIS audits had only identified overpayments of $2.4 million as of September 30, 2010. The remaining $8.4 million in overpayments were identified during the test audit phase, in which states identified the audit targets and supplied their own MMIS data. We continue to believe that CMS should more fully report on NMAP expenditures and audit outcomes in its annual reports and provide an overall assessment of NMAP in its next comprehensive plan. HHS concurred with our recommendation that CMS should clearly address NMAPs strengths, weaknesses, and effectiveness in the agency’s annual reports to Congress. HHS noted that in CMS’s December 7, 2011 congressional testimony the agency had reported its awareness of the limitations of MSIS data and outlined steps to improve contractors’ access to better quality Medicaid data. HHS also concurred with our recommendation that CMS’s use of NMAP contractors should support and expand states’ own audit activities, engage other willing states, and explicitly consider state burden when conducting collaborative audits. HHS reported that since February 2012 CMS had increased the number of collaborative audits by 25—from 112 audits in 11 states to 137 in 15 states. Based on HHS comments, we made technical changes as appropriate. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies to the Secretary of Health and Human Services, the Acting Administrator of CMS, appropriate congressional committees, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staffs have any questions about this report, please contact me at (202) 512-7114 or yocomc@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Major contributions to this report are listed in appendix V. Total (percent) 59 (4) 296 (19) 355 (23) 118 (8) 1,077 (69) 1,550 (100) The 59 MSIS audits that successfully identified potential overpayments were conducted in 16 states, and most of these audits involved hospitals (30 providers) and pharmacies (17 providers). These provider types also had the highest potential overpayments—over $6 million for hospitals and $600,000 for pharmacies. Arkansas and Florida accounted for over half of the audits that identified potential overpayments, but the most substantial overpayments were in Delaware ($4.6 million) and the District of Columbia ($1.7 million). (See tables 3 and 4.) Total (percent) 18 (16) 6 (5) 24 (21) 85 (76) 3 (3) 112 (100) Carolyn L. Yocom at (202) 512-7114 or yocomc@gao.gov. In addition to the contact named above, key contributors to this report were: Water Ochinko, Assistant Director; Sean DeBlieck; Leslie V. Gordon; Drew Long; and Jasleen Modi. National Medicaid Audit Program: CMS Should Improve Reporting and Focus on Audit Collaboration with States. GAO-12-814T. Washington, D.C.: June 14, 2012. Program Integrity: Further Action Needed to Address Vulnerabilities in Medicaid and Medicare Programs. GAO-12-803T. Washington, D.C.: June 7, 2012. Medicaid: Federal Oversight of Payments and Program Integrity Needs Improvement. GAO-12-674T. Washington, D.C.: April 25, 2012. Medicaid Program Integrity: Expanded Federal Role Presents Challenges to and Opportunities for Assisting States. GAO-12-288T. Washington, D.C.: December 7, 2011. Fraud Detection Systems: Additional Actions Needed to Support Program Integrity Efforts at Centers for Medicare and Medicaid Services. GAO-11-822T. Washington, D.C.: July 12, 2011. Fraud Detection Systems: Centers for Medicare and Medicaid Services Needs to Ensure More Widespread Use. GAO-11-475. Washington, D.C.: June 30, 2011. Improper Payments: Recent Efforts to Address Improper Payments and Remaining Challenges. GAO-11-575T. Washington, D.C.: April 15, 2011. Status of Fiscal Year 2010 Federal Improper Payments Reporting. GAO-11-443R. Washington, D.C.: March 25, 2011. Medicare and Medicaid Fraud, Waste, and Abuse: Effective Implementation of Recent Laws and Agency Actions Could Help Reduce Improper Payments. GAO-11-409T. Washington, D.C.: March 9, 2011. Medicare: Program Remains at High Risk Because of Continuing Management Challenges. GAO-11-430T. Washington, D.C.: March 2, 2011. Opportunities to Reduce Potential Duplication in Government Programs, Save Tax Dollars, and Enhance Revenue. GAO-11-318SP. Washington, D.C.: March 1, 2011. High-Risk Series: An Update. GAO-11-278. Washington, D.C.: February 2011. Medicare Recovery Audit Contracting: Weaknesses Remain in Addressing Vulnerabilities to Improper Payments, Although Improvements Made to Contractor Oversight. GAO-10-143. Washington, D.C.: March 31, 2010. Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States. GAO-09-1004T. Washington, D.C.: September 30, 2009. Medicaid: Fraud and Abuse Related to Controlled Substances Identified in Selected States. GAO-09-957. Washington, D.C.: September 9, 2009. Improper Payments: Progress Made but Challenges Remain in Estimating and Reducing Improper Payments. GAO-09-628T. Washington, D.C.: April 22, 2009. Medicaid: Thousands of Medicaid Providers Abuse the Federal Tax System. GAO-08-239T. Washington, D.C.: November 14, 2007. Medicaid: Thousands of Medicaid Providers Abuse the Federal Tax System. GAO-08-17. Washington, D.C.: November 14, 2007. Medicaid Financial Management: Steps Taken to Improve Federal Oversight but Other Actions Needed to Sustain Efforts. GAO-06-705. Washington, D.C.: June 22, 2006. Medicaid Integrity: Implementation of New Program Provides Opportunities for Federal Leadership to Combat Fraud, Waste, and Abuse. GAO-06-578T. Washington, D.C.: March 28, 2006.

Summary: Medicaid, the joint federal-state health care financing program for certain low-income individuals, has the second-highest estimated improper payments of any federal program. The Deficit Reduction Act of 2005 expanded the federal role in Medicaid program integrity, and the Centers for Medicare & Medicaid Services (CMS), the federal agency that oversees Medicaid, established the MIG, which designed the NMAP. Since the NMAPs inception, the MIG has used three different audit approaches: test, MSIS, and collaborative. This report focuses on (1) the effectiveness of the MIGs implementation of NMAP, and (2) the MIGs efforts to redesign the NMAP. To do this work, GAO analyzed MIG data, reviewed its contractors reports, and interviewed MIG officials, contractor representatives, and state program integrity officials. Compared to the initial test audits and the more recent collaborative audits, the majority of the Medicaid Integrity Groups (MIG) audits conducted under the National Medicaid Audit Program (NMAP) were less effective because they used Medicaid Statistical Information System (MSIS) data. MSIS is an extract of states claims data and is missing key elements, such as provider names, that are necessary for auditing. Since fiscal year 2008, 4 percent of the 1,550 MSIS audits identified $7.4 million in potential overpayments, 69 percent did not identify overpayments, and the remaining 27 percent were ongoing. In contrast, 26 test audits and 6 collaborative auditswhich used states more robust Medicaid Management Information System (MMIS) claims data and allowed states to select the audit targetstogether identified more than $12 million in potential overpayments. Furthermore, the median amount of the potential overpayment for MSIS audits was relatively small compared to test and collaborative audits. The MIG reported that it is redesigning the NMAP, but has not provided Congress with key details about the changes it is making to the program, including the rationale for the change to collaborative audits, new analytical roles for its contractors, and its plans for addressing problems with the MSIS audits. Early results showed that this collaborative approach may enhance state program integrity activities by allowing states to leverage the MIGs resources to augment their own program integrity capacity. However, the lack of a published plan detailing how the MIG will monitor and evaluate NMAP raises concerns about the MIGs ability to effectively manage the program. Given that NMAP has accounted for more than 40 percent of MIG expenditures, transparent communications and a strategy to monitor and continuously improve NMAP are essential components of any plan seeking to demonstrate the MIGs effective stewardship of the resources provided by Congress. GAO recommends that the CMS Administrator ensure that the MIGs (1) update of its comprehensive plan provide key details about the NMAP, including its expenditures and audit outcomes, program improvements, and plans for effectively monitoring the program; (2) future annual reports to Congress clearly address the strengths and weaknesses of the audit program and its effectiveness; and (3) use of NMAP contractors supports and expands states own program integrity efforts through collaborative audits. HHS partially concurred with GAOs first recommendation commenting that CMSs annual report to Congress was a more appropriate vehicle for reporting NMAP results than its comprehensive plan. HHS concurred with the other two recommendations.