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[HEALTH] · United States · 6 sources

started · updated

CMS issues guidance on Medicare and Medicaid improper payments

Centers for Medicare & Medicaid Services improper payments Medicaid compliance Medicare parenteral nutrition healthcare documentation

The Centers for Medicare & Medicaid Services (CMS) has released updates regarding improper payment rates and compliance requirements for both Medicare and Medicaid programs.

For Medicare, CMS reported a 33% improper payment rate for parenteral nutrition, with an estimated cost of $81.9 million. Insufficient documentation accounted for 69.4% of these errors. To ensure compliance, practitioners must provide medical documentation proving the necessity of parenteral nutrition and ruling out enteral nutrition.

Regarding Medicaid, CMS estimated an improper payment rate of 6.12% for fiscal 2025, totaling approximately $37.39 billion. Approximately 77.17% of these payments were attributed to insufficient documentation rather than fraud.

New regulatory pressures, including H.R. 1, have introduced work requirements and more frequent eligibility checks. Additionally, starting in 2029, states with eligibility-related improper payment rates exceeding 3% will face reductions in federal matching funds. These requirements place a disproportionate operational and financial burden on smaller, community-based health plans compared to larger integrated systems.

Entities

California Association of Health Plans · Centers for Medicare & Medicaid Services · Medicaid · Medicare

Claims

What the coverage asserts, and how many sources carry each claim.

  • [○ 1 SOURCE] CMS projected improper parenteral nutrition payments at $81.9 million. hme-business.com
  • [● 2 SOURCES] 77.17% of Medicaid improper payments resulted from insufficient documentation. krdo.com · kesq.com
  • [● 2 SOURCES] Medicaid improper payments for fiscal 2025 are estimated at $37.39 billion. krdo.com · kesq.com
  • [○ 1 SOURCE] The improper payment rate for Medicare parenteral nutrition was 33% in 2024. hme-business.com
  • [○ 1 SOURCE] Insufficient documentation caused 69.4% of improper parenteral nutrition payments in 2024. hme-business.com
  • [● 2 SOURCES] States with eligibility-related improper-payment rates above 3% face federal matching fund reductions starting in 2029. krdo.com · kesq.com
  • [● 2 SOURCES] The estimated Medicaid improper-payment rate for fiscal 2025 is 6.12%. krdo.com · kesq.com

Sources

CMS Publishes Medicare Compliance Tips for Parenteral Nutrition [hme-business.com]
Same Medicaid rules, unequal resources: Smaller plans face bigger corrective action plan risk [kioncentralcoast.com]
Same Medicaid rules, unequal resources: Smaller plans face bigger corrective action plan risk [krdo.com]
Same Medicaid rules, unequal resources: Smaller plans face bigger corrective action plan risk [localnews8.com]
Same Medicaid rules, unequal resources: Smaller plans face bigger corrective action plan risk [kesq.com]
Same Medicaid rules, unequal resources: Smaller plans face bigger corrective action plan risk [kvia.com]