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Report (OEI-09-08-00370)

04-17-2012
The Medicare-Medicaid (Medi-Medi) Data Match Program

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Summary

WHY WE DID THIS STUDY

The Medicare-Medicaid Data Match program (Medi-Medi program) enables program safeguard contractors (PSC) and participating State and Federal Government agencies to collaboratively analyze billing trends across the Medicare and Medicaid programs to identify potential fraud, waste, and abuse. Participation is optional. The Social Security Act mandates that the Medi Medi program increase the effectiveness and efficiency of the Medicare and Medicaid programs through cost avoidance (i.e., prepayment denials); savings; and recoupment of fraudulent, wasteful, or abusive expenditures.

HOW WE DID THIS STUDY

We analyzed data collected from CMS, PSCs, State Medicaid program integrity agencies, and other Federal and State agencies participating in the Medi-Medi program. The period of our review was 2007 and 2008.

WHAT WE FOUND

The Medi-Medi program produced limited results and few fraud referrals. During 2007 and 2008, the program-in which 10 States had chosen to participate-received $60 million in appropriations and it avoided and recouped $57.8 million. The program produced 66 referrals to law enforcement, and law enforcement accepted 27 of these. Among the 10 participating States collectively, each State averaged 2.8 Medicare referrals to law enforcement per year; law enforcement accepted an average of 1.15 referrals per State per year. In comparison, each State averaged 0.5 Medicaid referrals to law enforcement per year; law enforcement accepted an average of 0.2 referrals per State per year. Also, State Medicaid programs received less benefit from the Medi-Medi program than Medicare received. Of the $46.2 million total in Medicare and Medicaid expenditures recouped through the program during 2007 and 2008, more than three quarters-$34.9 million-was recouped for Medicare.

WHAT WE RECOMMEND

We recommend that CMS reevaluate the goals, structure, and operations of the Medi Medi program to determine what aspect of the program, if any, should be part of CMS's overall program integrity strategy. CMS concurred with our recommendation. CMS commented that since the period of our review, it has made significant strides in enhancing the effectiveness of the Medi Medi program. However, since our period of review, CMS has not provided any data to illustrate enhanced effectiveness, such as the number of referrals, accepted referrals, and the actual-not potential-Medicare and Medicaid expenditures avoided and recouped through the program. These data would enable Congress to make an informed decision whether to continue funding the program and enable State and Federal agencies to make an informed decision whether to participate.

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Exclusions Database Report Fraud
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