Mississippi will audit Medicaid providers as a part of federal fraud probe

By Gwen Dilworth | Originally published by Mississippi Today

Mississippi by June will begin reviewing the eligibility of Medicaid providers deemed high risk for fraud as part of a Trump administration effort to weed out potential waste and abuse in the program. 

Dr. Mehmet Oz, administrator for the Centers for Medicare and Medicaid Services, sent a letter on April 23 to Republican Gov. Tate Reeves and Mississippi Medicaid Director Cindy Bradshaw, along with officials in all 50 states, directing them to share plans to swiftly revalidate high-risk Medicaid providers within 10 days and provide a two-year strategy for reviewing all providers within 30 days. 

“Our analysis of national trends strongly suggests a persistent and growing Medicaid threat posed by sophisticated actors knowingly exploiting these complex systems for financial gain,” Oz wrote.

In an April 30 reply to Oz obtained by Mississippi Today, Reeves said Mississippi will recertify all high-risk Medicaid providers not reviewed in the past year and the state will provide a plan for reviewing all providers to CMS within the 30-day deadline.

“I too share this critical commitment and look forward to working with our partners at CMS to ensure our Medicaid members receive high quality care from qualified and ethical providers,” Reeves wrote. 

Spokespersons for Reeves and the Mississippi Division of Medicaid did not respond to Mississippi Today’s questions about how they plan to execute the federal directives. Mississippi Medicaid spokesperson Matt Westerfield did not respond to questions about how Mississippi currently defines low-, medium- and high-risk providers. 

Federal regulations require state Medicaid agencies to screen all Medicaid providers at least once every five years. States must provide more stringent reviews of providers they determine could pose a high risk of financial fraud, waste or abuse to the program. 

Oz’s April request to states is a part of a broader federal campaign to reduce waste, fraud and abuse in public benefit programs. These efforts have been a priority of the Trump administration, though earlier efforts were focused primarily on Democratic-led states. The administration launched healthcare fraud investigations in California, Florida, Maine, Minnesota and New York this year before expanding its efforts to all states. 

Much of the administration’s focus on eliminating healthcare fraud has been concentrated on Minnesota. In February, Vice President JD Vance announced the federal government would withhold $249 million in federal Medicaid funding from Minnesota due to fraud concerns. States and the federal government share the cost of Medicaid programs. 

In response, Minnesota Attorney General Keith Ellison and the state’s Department of Human Services filed a lawsuit arguing the federal government was illegally withholding Medicaid payments and jeopardizing health insurance access for more than 1 million Minnesotans enrolled in the program. 

The Mississippi Division of Medicaid, which administers health coverage to nearly 700,000 children and low-income pregnant, disabled or elderly Mississippians, paused the provider revalidation process during the COVID-19 pandemic, when some federal regulations were loosened, but resumed the reviews in October 2023, according to the Mississippi Division of Medicaid website. 

The agency revalidated 397 high-risk providers in the past year, accounting for 43% of the program’s high-risk providers, Reeves said in his April 30 letter to Oz. The letter did not say if any providers failed the revalidation process. 

Oz has called for states to review high-risk providers more frequently than federal law requires and implement more stringent reviews of those without a National Provider Identifier, a number used to identify covered healthcare providers. It is more common for atypical providers, or those who don’t deliver traditional medical services, like non-emergency medical transportation providers and personal care attendants, to lack an NPI, though they can acquire one. 

Reeves said in his letter to Oz that Mississippi’s risk levels are assigned “at or above the established risk levels of CMS,” and that all atypical providers, including those without an NPI, are designated high-risk. He said providers may also be elevated to high-risk status based on audit findings. 

Andy Schneider, a research professor at the Georgetown University McCourt School of Public Policy, acknowledged that a universal NPI requirement could be useful, but said he is not aware of evidence that suggests providers without NPIs commit fraud more frequently than those that do have the identifier. 

“Would it be better if everyone had an NPI? Sure,” Schneider said. “But that hasn’t been a requirement.” 

Khaylah Scott, program manager for Mississippi Health Advocacy Program, said it is important to ensure the process of revalidating providers without NPIs is completed carefully to ensure it does not jeopardize the care of people served by atypical providers, which often include seniors and disabled people. 

“It would be very unfortunate to see them go without their services because this process was done too swiftly,” Scott said.  

The call to complete a swift revalidation of providers comes as the Mississippi Division of Medicaid faces a vast budgetary shortfall. Lawmakers’ appropriation for the fiscal year that begins July 1 fell about $190 million short of what the agency requested. 

At the April 17 Medicaid Advisory Committee Meeting, Chief of Staff Jennifer Wentworth said the budget gap amounts to roughly $600 million to $700 million when factoring in the federal match funds Mississippi won’t receive as a result of the undersized state appropriation. 

This estimate could change when new actuarial reports are released, Bradshaw added, but the agency will likely need state lawmakers to appropriate additional money next year to cover the shortfall, or the agency could also be forced to cut provider payments. 

“I anticipate that it’s going to be a strategy of walking a thin line between making some cuts where we can, maybe implementing some rate increases … along with, in January, we will probably ask for a deficit appropriation, though I don’t think we’re even close to knowing what that amount will be,” Bradshaw said. 

The cost of completing the revalidation process will depend on how large the number of providers is and how many have recently been validated, Schneider said. 

He said the reviews could uncover bad actors diverting money away from the program and thus create savings for states, but the process can also be costly, time-consuming work for states with limited resources. 

“If you’re looking at the $600 million hole, this is not going to help you fill it,” Schneider said. 

According to the Mississippi Division of Medicaid’s 2024 annual report, the agency recovered $2.3 million through efforts by the Medicaid Office of Program Integrity to detect and prevent fraud and abuse. The office reported 205 open investigations that year and referred four cases to the Mississippi Medicaid Fraud Control Unit, operated by the state attorney general, for further investigation or prosecution. 

Scott said while efforts to address fraud are critical, she has concerns that the revalidation process could have harmful effects, particularly as Mississippi’s Medicaid program faces significant budget pressures and amid federal efforts to freeze funding to states. 

“I just hope that it’s done with the most vulnerable populations in mind,” Scott said. 

This article was originally published by Mississippi Today and is republished here under a Creative Commons license.

Source: Original Article