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Medicaid Financial Oversight Analysis

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Improving the financial integrity of Medicaid and the Children’s Health Insurance Program
  • Funder
    Centers for Medicare & Medicaid Services (CMS)
  • Dates
    2021 - Present

With funding from the Centers for Medicare and Medicaid Services (CMS), NORC at the University of Chicago is supporting the Center for Medicaid and CHIP Services (CMCS) with recommendations to increase the accountability and improve the financial integrity of state Medicaid and CHIP programs. The project involves strategic research, analysis, and financial management oversight activities for CMCS's Financial Management Group (FMG). NORC is leading a team with partners KPMG LLP and Chickasaw Management Services, LLC to conduct qualitative and quantitative analyses as part of this 4.5-year project (2021 - 2026).

Our activities include:

  • Analyzing quarterly Medicaid and CHIP expenditures reported on the CMS-37, CMS-64, CMS-21B, and CMS-21 forms via the Medicaid Budget and Expenditure System (MBES) and Medicaid and CHIP Financial System (MACFin). The NORC team will conduct quantitative analysis of these quarterly financial reporting data to identify single and multi-quarter Medicaid and CHIP expenditure anomalies or outliers that may require corrective action. The NORC team is also developing a data visualization dashboard using MBES data to help CMCS analysts quickly and comprehensively identify reporting anomalies requiring investigation.
  • Regularly monitoring and synthesizing government (e.g., CMS, U.S. Government Accountability Office, U.S. Department of Health and Human Services Office of Inspector General, etc.) and watchdog reports related to Medicaid and CHIP program financing and financial integrity. The NORC team will identify financing and financial integrity issues and develop actionable recommendations to CMCS FMG on how these reports inform oversight processes for Medicaid and CHIP expenditures reported by states.
  • Conducting financial management reviews (FMRs) of state-reported Medicaid expenditures to examine the appropriateness of Medicaid program reimbursement and federal payments. The NORC team is analyzing Medicaid managed-care contracts, state plan amendments, and 1115 waivers, among other policy documents, as well as samples of claims, encounter, and clinical data to determine the appropriateness of Medicaid payments to states.
  • Providing recommendations to CMCS FMG on enhancing overall Medicaid and CHIP financial management and oversight activities.
  • Providing technical assistance to CMCS and states to improve Medicaid and CHIP program oversight capabilities and to help ensure that payments are based solely on allowable expenditures under the programs.

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