Medicaid Integrity Provider Education Program

The Deficit Reduction Act (DRA) of 2005, which created the Medicaid Integrity Program (MIP), and Executive Order 13520, which called for the reduction of improper payments by intensifying efforts to eliminate payment error, waste, fraud, and abuse in the major programs administered by the Federal Government, directed the need for a program that would educate providers and other stakeholders and enhance awareness of Medicaid fraud, waste and abuse. Additionally, recent events in the news, the Office of Inspector General (OIG) report on the use of Atypical Antipsychotics in the elderly Medicare nursing home population, and various Congressional inquiries regarding prescription drug abuse brought great attention to the need for alternative solutions to enhance compliance to Federal standards. More specifically, the Centers for Medicare & Medicaid Services (CMS) was asked to identify ways to improve access to information necessary to ensure accurate coverage and reimbursement determinations and to find solutions to decrease fraud, waste, and abuse associated with prescription drug utilization and diversion.

The Center for Program Integrity, Medicaid Integrity Group (MIG), in collaboration with States, is providing education resources through its Education Medicaid Integrity Contractor (Education MIC) to promote best practices for five therapeutic drug classes that have been identified as having high potential for improper payment.  These best practices were designed to combat overprescribing and/or overutilization, while enhancing quality of care. Materials focused on the importance of prescribing drugs within the dosage guidelines approved by the Food and Drug Administration (FDA).  Five therapeutic drug classes consistently found among the top ten highest potential improper payments in Medicaid are atypical antipsychotics, proton pump inhibitors (PPIs), stimulants, anticonvulsants/antiepileptics, and antidepressants.

These fact sheets were prepared by the Education MIC for CMS, MIP. E-mail Medicaid Provider Education if you have questions or would like to obtain other provider education materials.