Strengthening Medicaid Program Integrity at NAMPI 2024

The 2024 National Association of Medicaid Program Integrity (NAMPI) Annual Conference in New Orleans brought together nearly 1,000 in-person and virtual attendees from all states and several territories to discuss opportunities to better control fraud, waste, and abuse in Medicaid. It was an invigorating week of insightful sessions, productive dialogue, and collective celebration of the critical work being done to ensure Medicaid continues to serve vulnerable populations as intended. 

HMS, a Gainwell Technologies Company, was there, representing the work we’re doing to help states and healthcare organizations contain healthcare costs. From a panel session introducing a novel approach to provider audits to an evening of fun and connection with clients and colleagues, we were proud to sponsor and support this important gathering. Here are some of our top takeaways.  

Innovating Provider Audits 

Provider auditing, the process of validating that medical services are being coded and billed as rendered, is a vital payment integrity function. However, these reviews have traditionally been a source of abrasion and administrative burden for payers and providers alike, particularly when there’s a need to request medical records from the provider.  

At NAMPI, many discussions centered on strategies for improving this process to be more provider-centric and less burdensome. For our part, HMS payment integrity experts Gary Call, M.D., Shane Abing, and Greg Fischer presented on the growing trend of “moving payment integrity to the left” — adopting pre-payment approaches to avoid improper payments, the need to rework claims on the back end, and recoup overpayments from providers.  

HMS’ Intelligent Review approach takes it a step further by leveraging machine learning, analytics, and historical clinical expertise to target claims with the highest probability of overpayment, bypassing medical record reviews. It’s a solution validated through rigorous testing of more than 1,800 claims using proprietary algorithms and delivering 94% accuracy and $8.8 million in client savings. As Dr. Call expressed, providers are never going to love being audited; however, the data and technology exist to streamline the process substantially while driving greater payment accuracy and provider satisfaction.  

Enhancing Oversight in Medicaid Managed Care 

With Medicaid Managed Care Organizations (MCOs) or Managed Care Plans (MCPs) playing an increasingly vital role in service delivery, there is a growing need for states to maintain strong oversight and ensure accountability of these entities. In sessions throughout the conference, CMS spoke about its expanded oversight of MCPs to include new areas such as denied services, prior authorizations, network adequacy, and the delivery of preventive services. These efforts are aimed at ensuring MCPs are not only compliant with regulations but also effective in providing the care Medicaid beneficiaries need.  

Robust analytics provide critical insight into states’ managed care networks, and our own Kim Butler was on site to demonstrate our MCO analytics capabilities powered by our GainwellGenius™ platform.  

Advancing Fraud Detection and Prevention 

The fight against Medicaid fraud is an ongoing challenge. As technology advances, so too do fraud schemes — becoming ever more sophisticated and the impacts more severe.  

Fortunately, the tools we have to combat fraud, waste, and abuse are growing more sophisticated as well. As the NAMPI community underscored the need for advanced strategies in fraud detection and prevention, Julia Twaddle, CFE, was busy demonstrating how exactly we’re accomplishing this at HMS — engaging in 1:1 discussions with state clients about the self-service solutions and investigative support available through HMS’ FraudCapture® platform.  

If you missed Julia at the conference, check out her recent webcast highlighting everything states need to know about the recent DOJ crackdown on healthcare fraud.  

Building Connections in the Big Easy 

Serious subject matter warranted serious time to connect and unwind. On the third day of the conference, HMS team members gathered with clients and the broader NAMPI community at the famous Red Fish Grill in the historic heart of New Orleans’ French Quarter. The NAMPI-hosted, Gainwell-sponsored event offered a great opportunity to reflect on the insights shared and renewed energy from the days’ sessions while enjoying delicious local cuisine, lively conversation, and Mardi Gras-themed flair in a vibrant and relaxed setting.  

A Unified Effort to Safeguard Medicaid 

Conversations and insights at NAMPI are pivotal to enhancing Medicaid program integrity and ensuring the long-term sustainability of this vital safety net system. The collaborative spirit and innovative thinking shared is reverberating across our teams as we remain firm in our commitment to ensuring Medicaid’s ability to meet the needs of the populations it serves. A big thank you to NAMPI and all who joined to make this year’s gathering one of the best yet.