Reports & Guidance

Reports & Guidance

Find resources to help you understand the ins and outs of CMS’ program integrity efforts, and read the annual reports that we submit to Congress about our center and our programs.

Reports to Congress

Medicare and Medicaid Integrity Programs
Read the annual reports of CMS' efforts, through the Center for Program Integrity, to combat fraud, waste and abuse of the Medicare, Medicaid and Marketplace programs.

Open Payments Program
Read annual overviews of the Open Payments program and payments reported by applicable manufacturers and group purchasing organizations to physicians and teaching hospitals.

 

Medicaid Program Integrity Reports

Comprehensive Medicaid Integrity Plan, FY 2019 - FY 2023 (PDF)
Explore the 5-year, comprehensive plan to protect taxpayer dollars in the Medicaid program by combatting fraud, waste and abuse.

Beneficiary Eligibility Reviews
As part of the Comprehensive Medicaid Integrity Plan for FYs 2019-2023 and the Medicaid Program Integrity Strategy, CMS is conducting beneficiary eligibility reviews. The primary goal of these reviews is to confirm that states’ Medicaid and Children’s Health Insurance Program (CHIP) beneficiary eligibility determinations are appropriate and that the federal match is correctly assessed.

Completed Medicaid and CHIP beneficiary eligibility review reports are included below:

California Medical Loss Ratio Examination Report (PDF)
A key component of CMS’ managed care program integrity work is to conduct targeted examinations of selected states’ Medicaid Managed Care Plans’ (MCPs) financial reporting.  As part of this effort, CMS conducted an examination of the Medical Loss Ratio (MLR) reported by California’s 22 Medicaid MCPs to determine if the state’s previous review correctly identified findings and overpayments, and the documentation accepted by the state was reasonable to support the amounts included in the MLR calculation.

State Program Integrity Review Reports, 2007 – 2019
State program integrity (PI) review reports, and respective follow-up review reports, provide CMS' assessment of the effectiveness of States' Medicaid PI efforts, including compliance with Federal statutory & regulatory requirements.

 

Other Program Integrity Reports

Fraud Prevention System Return on Investment, 2015 (PDF)
A one-time high-level summary of the Fraud Prevention System (FPS) savings and return on investment. The FPS helps identify and prevent inappropriate payments.

 

Stay Up to Date with CPI

Connect with CPI as we host or attend various events throughout the year, join our mailing list to stay informed on Program Integrity news, or find the most appropriate vehicle to report suspected fraud, waste, or abuse.

Page Last Modified:
01/28/2021 11:34 AM