Key Players
HCR 460: Investigations and Disclosures in Health Care Compliance
October 15, 2023
Three key players at the federal level are the Medicaid and CHIP Payment and Access Commission (MACPAC), the Centers for Medicare and Medicaid Services (CMS), and the Congressional Research Service (CRS). The requirements for States to receive Medicaid funds are to provide managed care, waiver, state plan amendment review, contract review, readiness review, payment review, state monitoring system, quality strategy, development access standards, external quality review, and annual program report (MACPAC. N.d.). The requirements for conditions for coverage (CfCs) and conditions of participation (CoPs) are to acquire proper accreditation of accrediting organizations that are recognized by CMS (CMS. 2023). Eligibility coverage by Medicaid is for low-income individuals, pregnant women, parents of dependent children, the elderly, and people with disabilities (MACPAC. N.d.). These requirements are important for each key player because, at times, there are only so many funds for so many individuals, unfortunately, coverage is not for everyone when it comes to eligibility and specific coverages.
There are going to be advantages and disadvantages when it comes to eligibility requirements on any type of funding but today the focus is on health care and funding for federal programs. One of the disadvantages is the eligibility to who can gain coverage from Medicaid and who is unable to gain coverage such as when it comes to income. The income is at a disadvantage due to inflation and the debt system. I bring up the debt system due to impossible APR rates and other interest rates. This can cause some incomes to seem livable to be non-livable because not only do credit companies have APR rates but also the inflation of necessities such as food, medications, and even house payments can rise, etc. This can cause issues when it comes to medical costs and health coverage due to having a non-livable income.
Just because there are disadvantages doesn’t mean there aren’t any advantages because there are advantages to this. When it comes to states acquiring Medicaid coverage, the state must abide by rules created by MACPAC in order to provide adequate care and proper monitoring to ensure fraud, waste, and abuse are not happening (MACPAC. N.d). This includes requiring the state to give as much information and details as possible to the enrollees such as covered benefits, enrollment process, and enrollment in managed care (MACPAC. N.D). Another advantage is that Medicaid provides what the payment rates are going to be with the covered entity, so they follow the state and federal rules (CRS. 2023). The advantage to all of these is to ensure that improper payments are paid back to Medicaid when it comes to paying for fraud, waste, and abuse (CRS. 2023).
The ten guiding rules are needed to know, control, and track information, fully debrief complainants, chain of custody, be fair and impartial, include management’s view, exercise discretion, stay focused and flexible, be comprehensive, and prevent retaliation (Kusserow. N.d.). The need-to-know basis should only consist of what needs to be talked about and not about how things may or may not turn out (Kusserow. N.d.). The control and track information is keeping up on all reports via hotlines and they should be logged and dated (Kusserow. N.d.). The chain of custody is tracking evidence that is collected during the investigation (Kusserow. N.d.). Being fair and impartial is when the investigator is impartial to the point that fairness is involved when collecting and reviewing all facts that are relevant to the case (Kusserow. N.d.).
References
· Medicaid and CHIP Payment and Access Commission (MACPAC). N.d. Key Federal Program Accountability Requirements in Medicaid Managed Care. Retrieved from https://www.macpac.gov/subtopic/key-federal-program-accountability-requirements-in-medicaid-managed-care/
· Centers for Medicare and Medicaid Services (CMS). 2023, September 06. Conditions for Coverage (CfCs) and Conditions of Participation (CoPs). Retrieved from https://www.cms.gov/medicare/health-safety-standards/conditions-coverage-participation
· Congressional Research Service (CRS). 2023, February 08. Medicaid: An Overview. Retrieved from https://crsreports.congress.gov/product/pdf/R/R43357
· Richard Kusserow. N.d. Conducting Internal Investigations in Healthcare Compliance Using Ten Guiding Rules. Retrieved from https://www.compliance.com/wp-content/uploads/2019/09/Conducting-Internal-Investigations-Using-Ten-Guiding-Rules_RPK.pdf