Smart compliance for Medicaid

Government regulations can be lengthy and reviewing their supporting documentation, such as Federal Register entries and SMDLs, adds to the level of effort needed to digest a regulation’s full intent. The manual effort needed to monitor, identify, and review these documents is not a small task. Capitalizing on the efficiencies that technology can offer to support this process could reduce the burden on state staff. Leveraging tools such as AI could parse out regulations into the obligations that need to be followed, making it easier for agency staff to identify and manage the necessary changes. Technology can also be used to trigger the identification of changes to existing regulations, and even escalate changes based on risk profiles.

Both the accurate interpretation and accurate application of federal regulatory requirements are critical for state Medicaid agencies to run a compliant Medicaid program. If this level of accuracy doesn’t exist, then states are at risk of CMS issuing penalties, including the potential loss of funding. States can benefit from new innovations in regulatory monitoring tools to help maintain this level of rigor and better safeguard their federal Medicaid funds. Examples include technology that can automatically test requirements using an analytics-based approach and generate dashboards to monitor compliance.

Identifying a regulatory change is just the first step in the tracking process. States must also track whether a regulation is required or optional, what the impacts are, how the state will implement the changes, confirmation of the implementation results and other key functions needed to make a Medicaid policy change. States may use different tracking mechanisms for each of these steps and may also have different tracking mechanisms across different teams or program areas. Having a single consolidated system for tracking all Medicaid regulations across an agency can better enable agencies to make sure that nothing slips through the cracks and that regulatory changes implemented in one area don’t conflict with other areas. This level of regulatory change management can also be supported through automation of certain functions, such as technology that can absorb regulatory language and automatically map it to agency functions or programs.

The requirements for a government program as large as Medicaid should not be left up to subjective interpretation. The risk of noncompliance has serious implications not only for the state agencies that administer the program, but also for the people who depend on Medicaid for their health care. When agency processes are person dependent, different staff members may interpret a regulatory requirement differently. Even with supporting guidance such as SMDLs, there are risks to a requirement being misinterpreted or even missed. Using modern technology such as AI, paired with human review, to apply a consistent identification of regulatory language based on standardized rules can support states in their Medicaid program administration.

Benefits such as those listed above are just the tip of the iceberg. Since each state has its own unique processes and approach to managing its Medicaid program, individual states could realize additional benefits to modernizing their regulatory compliance strategy based on their unique circumstances. Focusing on enhancing a state’s Medicaid regulatory compliance approach and toolkit will help states both meet CMS requirements and deliver a program that effectively serves the people who depend on Medicaid for their care.