Medicaid: Quality Metrics Reporting, Georgia Work Requirements & Another Case of Medicaid Fraud

Last week, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule that aims to improve quality reporting for Medicaid and the Children’s Health Insurance Program (CHIP).

According to the CMS press release, the rule would include mandatory annual state reporting of three new quality measures, called “Core Sets,” which are designed to measure overall national quality of care for beneficiaries. The Core Sets will cover the Children’s Health Care Quality Measures for Medicaid and CHIP, the behavioral health measures for Adult Health Care Quality Measures in Medicaid, and for Health Home Quality Measures for Medicaid. The Core Sets include a range of measures focused on patient-centered care for low income people.

From CMS Administrator Chiquita Brooks-LaSure:

The Medicaid and CHIP Core Sets of quality measures for children, adults, and health home services are key to promoting health equity. They will allow us not only to identify health disparities but also to implement interventions based on the very data that make those disparities clear.

CMS is also encouraging states to improve nursing home care through existing Medicaid authorities. In line with President Joe Biden’s set of reforms for nursing home quality, accountability and transparency, CMS published an informational bulletin describing actions that states can take to improve outcomes for nursing home residents, improve staff pay, increase nursing home employee retention and increase training for staff members.

From U.S. Department of Health and Human Services Secretary Xavier Becerra:

At HHS, we’re taking another critical step to implement President Biden’s bold set of reforms to improve our nation’s nursing homes. We call on all states to work with us and ensure everyone has access to the high-quality care they deserve.

Last Friday, U.S. District Judge Lisa Godbey Wood reversed a Biden administration decision to revoke approval of the work requirement for Medicaid eligibility in Georgia and a related proposal to charge some Medicaid recipients monthly premiums. Associated Press reports that CMS has argued that the work requirement would have been impossible to meet during the pandemic, when access to health coverage was paramount.

Three health providers and a county-managed health plan have agreed to pay $70.7 million to the state of California and the federal government to settle claims of overbilling. According to Reuters, the three separate settlements stem from a whistleblower lawsuit brought by a former controller of the Ventura County Gold Coast Health Plan. The Gold Coast Health Plan is a County Organized Health System, an aspect of the California Medicaid program which allows some counties to operate managed care organizations for Medicaid beneficiaries.