Program Integrity | Simon&Co., LLC

Simon & Co. Tracks Status of Medicaid Recovery Audit Contracts

Simon&Co. — Fri, 11 Oct 2024 21:33:02 +0000

The Affordable Care Act requires state Medicaid agencies to establish a Medicaid Recovery Audit Contractor (RAC) absent an exception, to enable the auditing of claims for services furnished by Medicaid providers. States request an exception by submitting to CMS a revised State Plan amendment (SPA). Simon&Co. tracking of these SPAs shows most states have exceptions.

RAC Waiver Map Download

Medicaid_RAC_FAQ Download

CMS Frequently Asked Questions on Medicaid Recovery Audit Contractor program

Medicaid_RAC_FAQ Download

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House Passes Medicare and Medicaid Program Integrity Legislation

Simon&Co. — Fri, 11 Oct 2024 21:30:38 +0000

On September 17, 2024 the House of Representatives passed legislation to require states to check the Social Security Administration’s Death Master File (DMF) database on a quarterly basis and verify that Medicaid patients, providers and suppliers are not deceased, to require states to check provider and supplier states in termination databases, and to require Medicaid MCOs to regularly check beneficiary addresses. Read our summary below:

House Passes Medicare and Medicaid Program Integrity Legislation Download

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GAO COI Sustained, Issues with Firewall Plans in Proposal

Simon&Co. — Fri, 11 Oct 2024 21:26:13 +0000

In a recent protest decision (B-421792.2,B-421792.3, A Square Group), GAO determined that CMS did not consider the impact a proposed firewall would have on other bidder’s technical approach. The Request for Quotes sought a contractor to analyze activities in the Federally Facilitated Exchange (including reconciliation and validation of enrollment and payment data). Cogent People Inc., purposed a subcontractor that supports the FFE under a separate contract, but with a firewall between the work of this contract and the payments data generated by the subcontractor in its FFE contract.

In its decision, the GAO found fault in CMS evaluation of how Cogent would establish and handle the firewall. For instance, the GAO found Cogent did not show the staff separation in its organizational chart and proposed the subcontractor’s staff to perform aspects of the work subject to Organizational Conflicts of Interest. GAO also found CMS failed to evaluate the effect of the fire on the proposed technical approach. GAO recommended CMS reassesses its OCI analysis. This decision could mean that CMS contracting officers will be more stringent in their OCI and firewall reviews in the future.

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