Tag Archives: Patient Protection and Affordable Care Act

CMS in the Hot Seat for Lax Oversight of Medicaid Managed Care Organizations

LLA Headshot smBy Lenis L. Archer, J.D., M.P.H., The Health Law Firm

For years, each state has kept an eye on its own Medicaid managed care plans, while the Centers for Medicare and Medicaid Services (CMS) is required to monitor how well each individual state is doing. However, a recent Government Accountability Office (GAO) report claims CMS is sleeping on the job. The report, released on June 20, 2014, stresses the need for more federal oversight of these plans.

With the implementation of the Affordable Care Act (ACA), the Medicaid program is expected to expand significantly. Most of the new beneficiaries enrolled in managed care are covered almost entirely by federal funds. The need for federal oversight in this area is of growing importance to ensure accountability of taxpayers’ dollars.

To read the entire report from the GAO, click here.

Report Findings: MCOs Need to be Watched by the Feds.

The persistent theme of the GAO report is that CMS and the Department of Health and Human Services (HHS) have done little to control the integrity of managed care organizations (MCOs). Federal programs have delegated managed care supervision to each individual state, but fail to provide needed guidelines and resources. CMS has not updated its MCO program guidance since 2000.

The report found neither state nor federal programs are well positioned to identify improper payments made to MCOs. Further, these programs are unable to ensure that MCOs are taking appropriate actions to identify, prevent or discourage improper payments.

For example, the report looked at state program integrity (PI) units and Medicaid Fraud Control Units (MFCU) from seven states. These anti-fraud groups admitted to primarily focusing their efforts on Medicaid fee-for-service claims. Meanwhile, claims made to MCOs have flown under their radar.

GAO Recommendations.

The GAO recommends that CMS:

– Require states to conduct audits of payments to and by MCOs;

– Update its managed care guidance program integrity practices and effective handling of MCO recoveries; and

– Provide states with additional support in overseeing MCO program integrity.

The GAO also suggests that CMS increase its oversight, especially as states expand their Medicaid programs. The GAO report recommends CMS take a bigger role in holding states accountable to ensure adequate program integrity efforts in the Medicaid managed care program. If CMS does not step up to the plate, the report predicts a growing number of federal Medicaid dollars will become vulnerable to improper payments.

The Future of MCOs.

If this report is taken seriously, be assured that audits of MCOs will become more frequent and extensive. If CMS ramps up their efforts, claims could be reviewed in detail by Medicaid integrity contractors. Now is the time to verify you are in compliance and receiving proper payments; before CMS turns the magnifying glass on you or your facility .


What do you think of the GAO’s assessment of MCOs? Do you think CMS needs to step up and provide more oversight? Please leave any thoughtful comments below.

Contact Health Law Attorneys Experienced in Handling Medicaid Audits, Investigations and other Legal Proceedings.

Medicaid fraud is a serious crime and is vigorously investigated by the state MFCU, the Agency for Health Care Administration (AHCA), the Zone Program Integrity Contractors (ZPICs), the FBI, and the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS). Other state and federal agencies, including the U.S. Postal Service (USPS), and other law enforcement agencies often participate. Don’t wait until it’s too late. If you are concerned about possible violations and would like a confidential consultation, contact a qualified health attorney familiar with medical billing and audits today. Often Medicaid fraud criminal charges arise out of routine Medicaid audits, probe audits, or patient complaints.

The Health Law Firm’s attorneys routinely represent physicians, dentists, orthodontists, medical groups, clinics, pharmacies, assisted living facilities (AFLs), home health care agencies, nursing homes, group homes and other healthcare providers in Medicaid and Medicare investigations, audits and recovery actions. To contact The Health Law Firm please call (407) 331-6620 or (850) 439-1001 and visit our website at www.TheHealthLawFirm.com.


Mullaney, Tim. “Federal Government Needs to Boost Medicaid Managed Care Oversight, GAO Says.” McKnight’s Long-Term Care & Assisted Living. (June 20, 2014). From: http://www.mcknights.com/federal-government-needs-to-boost-medicaid-managed-care-oversight-gao-says/article/356779/

Adamopoulos, Helen. “GAI Calls on CMS to Increase Medicaid Managed Care Oversight.” Becker’s Hospital Review. (June 20, 2014). From: http://www.beckershospitalreview.com/finance/gao-calls-on-cms-to-increase-medicaid-managed-care-oversight.html

Bergal, Jenni. “Advocates Urge More Government Oversight of Medicaid Managed Care.” Kaiser Health News. (July 5, 2013). From: http://www.kaiserhealthnews.org/stories/2013/july/05/medicaid-managed-care-states-quality.aspx?referrer=search

About the Author: Lenis L. Archer is as attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone: (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.


First Year Pioneer ACO Results: Medicare Money Saved But Some Physicians Leave Program

Lance Leider headshotBy Lance O. Leider, J.D., The Health Law Firm

On July 16, 2013, the Centers for Medicare and Medicaid Services (CMS) issued a press release summarizing the performance results for the first year of the Pioneer Accountable Care Organization (ACO) Model. Made possible by the Patient Protection and Affordable Care Act (PPACA), the Pioneer ACO Model encourages providers and care givers to deliver more coordinated care ans services for Medicare beneficiaries. ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely, according to CMS.

Click here to read the entire press release from CMS.

Pioneer Model ACOs Increase Quality.

The press release states that all thirty-two (32) participants in the program successfully increased the quality of care received by their beneficiaries.  Consequently, each participant received incentive payments for achieving these results.

Some examples of the quality improvements were lower readmission rates and better blood pressure and cholesterol control among diabetic patients.  Some examples of the quality control measures that were implemented were:

–    dispatch of hospital trained nurses to beneficiaries’ homes for management of prescriptions, blood-sugar readings, healthy eating education and delivery and set up of durable medical equipment (DME); and

–    care coordination by trained healthcare professionals at no cost.

Pioneer Model ACOs Increase Savings.

Of the thirty-two (32) Pioneer ACOs, thirteen (13) of them produced shared savings with CMS.  This means that they exceeded the cost reduction benchmarks and were eligible to receive a percentage of those savings from CMS as compensation additional to the fee-for-service payments.  In total CMS estimates that approximately $87.6 million in Medicare expenditures was saved.

However, two (2) of the Pioneer ACO participants had shared losses.  This means that their per beneficiary fee-for-service expenditures exceeded the stated goal and they were required to share in the losses suffered by CMS.  These losses were approximately $4 million.

Some Pioneer Model ACOs Withdrawal From Program.

Of the Pioneer ACOs that did not produce shared savings, seven (7) of them have decided to leave the Pioneer program and enroll in the standard Medicare Shared Savings Program.  This program offers lower risks and lower rewards and does not have the option of moving to a capitated payment model after the first two (2) successful years.

The two (2) Pioneer ACOs that experienced shared losses with CMS have signaled their intent to withdraw from the ACO model entirely.

The First-Year Pioneer ACO Lesson: Win Some, Lose Some.

While not a total success, the Pioneer ACO program did manage to produce net savings to Medicare and improve the quality of care provided to its beneficiaries.  Many news outlets who oppose PPACA are citing this as a failure of the program and yet more bad news for President Obama’s healthcare overhaul.  However, many other sources share CMS’s somewhat rosier view of the program.  These sources state that while the program may not have been as big a success as hoped, it was only the first year in operation and is nowhere near a failure.

According to an article in American Medical News, the American Medical Association (AMA) supports ACO programs that have allowed physicians practicing in groups of various sizes to participate in new care models. The AMA states that the first-year pioneer results are encouraging, and have the potential to improve quality and decease costs. To read the entire article from American Medical News, click here.

Data should be released on the standard Shared Savings Program ACOs in the near future.

Contact Health Law Attorneys Experienced With Healthcare Business Practices.

The Health Law Firm routinely represents physician groups and practices with issues involving establishing, licensing, selling, merging, and intergroup affiliation.  If you are considering establishing an ACO or have been approached to become a participant in one, you can contact The Health Law Firm at (407) 331-6620 or (850) 439-1001 or you can visit our website at www.TheHealthLawFirm.com.


What do you think of the performance results summery for the first year Pioneer ACO Model? What do you think about the number of groups dropping out? Please leave any thoughtful comments below.


Centers for Medicare and Medicaid Services. “Pioneer Accountable Care Organizations Succeed in Improving Care, Lowering Costs.” CMS.gov. (July 16, 2013). From: http://cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

Fiegl, Charles. “Medicare pioneer ACOs save money but lose physicians.” American Medical News. (July 29, 2013). From: http://www.amednews.com/article/20130729/government/130729933/1/?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20130729

About the Author: Lance O. Leider is an attorney with The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida, area. www.TheHealthLawFirm.com  The Health Law Firm, 1101 Douglas Avenue, Altamonte Springs, Florida 32714, Phone:  (407) 331-6620.

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2012 The Health Law Firm. All rights reserved.