A recent report by the U.S. Department of Health and Human Services (HHS) has highlighted the severe outcomes of non-compliance with federal and state requirements for approving claims involving inpatient care for certain provider-preventable conditions (PPCs). According to the HHS report, the Missouri Department of Social Services (DSS) may end up reimbursing nearly $1.7 million in Medicaid or MO HealthNet payments to the federal government for something that could have been avoided. The Missouri state agency is said to have made payments for claims with several blank fields without considering the need for proper review.
The claims of MO HealthNet in the state of Missouri are paid with a mix of both federal and state funds. For Medicaid payments, both the federal government and states are expected to ensure utmost accuracy. In fact, the HHS has a multi-faceted strategy in place to measure the overall improper payment rate for Medicaid through the Payment Error Rate Measurement (PERM) program.
The DSS has been accused of not following the provisions of the Centers for Medicare & Medicaid Services (CMS)-approved state plan that mandates a clinical review of claims with diagnosis codes identified as PPCs. Moreover, the state agency paid claims for inpatient care with blank present-on-admission (POA) indicator data fields. The HHS report has identified that the DSS incorrectly excluded some diagnosis codes that were subject to the payment reduction and vice-versa. Experts attribute the current case of non-compliance with federal requirements to the lack of sufficient policies and guidelines to review claims in order to determine the need for adjusting payments.
Health economists nationwide may describe Medicaid as a cost-effective program for millions of economically weaker Americans, but critics call it the latest money-spinner in the country with growing instances of improper payouts. With big names in the health insurance industry using the taxpayer-funded program to make money, there is a growing sense of insurers getting richer at the expense of the poor. An analysis of state data by Kaiser Health News suggests that Health Net, which is a unit of the largest Medicaid insurer Centene Corporation, earned phenomenal profits of $1.1 billion from 2014 to 2016. Similarly, another well-known insurer Anthem reported profits of $549 million from California’s Medicaid program during the same period.
Studies show that in the early phase of Medicaid expansion under the Affordable Care Act (ACA), several Medicaid insurers across the country made huge money, especially during 2014-2016. However, experts believe with the finalization of retroactive rate adjustments and completion of audits, the federal and state governments would recover a significant amount of money lost in improper payments.
Various surveys show that many health insurers refuse to cover mental health and addiction problems. As a result, those grappling with mental disorders like depression and anxiety find it difficult to get a proper treatment. The 2017 report of Mental Health America (MHA) suggests that over 40 million individuals across the U.S. suffer from a mental problem and 56 percent of them still lack access to any kind of professional help or treatment.
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