H.R. 10615: Medicaid Integrity Improvement Act

This bill would require each State Medicaid fraud control unit to do annual audits of a statistically valid sample of high-risk Medicaid providers and suppliers. The goal is to help identify possible fraud, waste, and abuse in Medicaid.

What would change

• State Medicaid fraud control units would have to start these audits within 1 year after the bill becomes law.
• The audits would need to happen at least once every year after that.
• The audits would be done in coordination with the Department of Health and Human Services Inspector General and the relevant state Medicaid agency, when appropriate.

Who could be audited

The bill defines high-risk providers or suppliers to include Medicaid participants that are:

• Already classified as high-risk under federal provider screening rules; or
• Otherwise identified as high-risk because of factors such as:
  • unusual billing patterns,
  • past audits,
  • payment anomalies,
  • ownership-related concerns, such as changes in ownership or undisclosed ownership interests, or
  • credible allegations of fraud.

Reporting requirements

The annual report that these units already submit to the Secretary of Health and Human Services would have to include a summary of the new audits. That summary would need to explain:

• what audits were conducted, and
• how many overpayments were identified and collected, or referred for collection, based on those audits.

Exception for missed requirements

If the Secretary determines that a unit did not meet the annual-audit requirement, the unit could still be certified or recertified if it submits and carries out a corrective action plan that meets standards set by the Secretary.

Relevant Companies

None found