H.R. 10625: Medicaid Integrity Improvement Act

This bill would require each state Medicaid fraud control unit to do annual audits of a statistically valid sample of providers and suppliers that are considered high-risk. The audits would be done as part of the unit’s statewide anti-fraud program, and would be coordinated with the Department of Health and Human Services Inspector General and, when appropriate, the state agency that runs Medicaid.

What counts as “high-risk”

The bill defines high-risk providers or suppliers broadly. A provider could fall into this category if it:

• Is already classified as a high-risk provider under federal Medicaid screening rules, or
• Is flagged by the fraud control unit based on risk factors such as unusual billing patterns, previous audits, payment irregularities, ownership changes, hidden ownership interests, ties to sanctioned or investigated entities, or credible fraud allegations.

Reporting requirements

The bill would also require fraud control units to include information about these audits in their annual reports to the Secretary of Health and Human Services. That report would need to summarize:

• What audits were conducted, and
• How much in overpayments was identified and collected, or referred for collection, as a result.

Certification and corrective action

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

Practical effect

In plain terms, the bill would add a new yearly audit requirement aimed at finding Medicaid fraud, waste, and abuse more systematically, especially among providers and suppliers that appear more likely to have compliance problems. It would also increase reporting on what those audits uncover and allow a path to compliance through corrective action if a unit falls short.

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