Executing Payment Integrity Through Medicaid Managed Care
Medicaid managed care organizations (MCOs) strengthen payment integrity through wide-ranging efforts to address fraud, waste, and abuse (FWA). A comprehensive approach prevents improper payments before they occur, recovers improper payments, and complements states’ FWA efforts.
Payment integrity ensures that Medicaid funds are paid in the correct amount to the right care provider on behalf of the beneficiary for appropriate Medicaid-covered services. Elevance Health’s payment integrity framework includes a combination of front-end payment controls, provider engagement, advanced analytics, and targeted investigations, with activities tailored to the contractual and regulatory requirements of each state Medicaid program. Through this approach, Medicaid programs and their MCO partners can improve payment accuracy and reduce administrative burden while maintaining access for beneficiaries.
Related Public Policy Research
Potential Medicare Savings on Select Services Subject to Fraud, Waste & Abuse
Traditional Medicare could have saved $7 billion from 2019-2023 on four services, which the HHS Office of the Inspector General identified as subject to fraud, waste, and abuse—skin substitutes, catheters, genetic testing, and off-the-shelf orthotic braces—if its utilization rates mirrored those of Medicare Advantage.
Coding for High-Complexity Office Visits on the Rise
The percentage of outpatient evaluation and management visits (office visits) coded as high-complexity has increased by more than 50% since 2006, adding to overall and patient-paid costs.