CPI Medicaid Program Integrity Strategy
Medicaid Program Integrity Strategy
CMS has implemented new and enhanced initiatives to protect taxpayer dollars across states.
Milestones and Priorities
First Year
at a Glance ...
The Medicaid Program Integrity Strategy includes stronger audits and oversight functions, increased data sharing and partnerships, and additional education, technical assistance, and collaboration.
Audits & Oversight
What We're Doing...
- Conducting audits of beneficiary eligibility determinations in high-risk states identified by previous audit findings
- Implementing the revised Medicaid Eligibility Quality Control (MEQC) program for continuous oversight of states’ eligibility determinations
- Auditing Medicaid managed care plans’ financial reporting and Medical Loss Ratios (MLRs) to ensure plans aren’t being overpaid
What's coming...
- Address high-risk vulnerabilities though audits of state claiming of federal matching dollars
- Engage with states to conduct provider education through Targeted Probe and Educate (TPE) and Comparative Billing Reports
Data Sharing & Partnerships
What We're Doing...
- Enhancing data sharing and collaboration to tackle program integrity efforts in both the Medicare and Medicaid programs
- Optimizing Transformed Medicaid Statistical Information System (T-MSIS) data to help detect fraud, waste, and abuse
What's coming...
- Conduct provider screening on behalf of states for Medicaid-only providers
Education, Technical Assistance, and Collaboration
What We're Doing...
- Engaging with states to share promising program integrity practices identified by states
- Training and educating more than 1,000 state Medicaid program integrity staff through the Medicaid Integrity Institute (MII) annually
- Providing guidance and assistance for implementation of Medicaid provider screening and enrollment for Medicaid managed care organization networks
- Conducting State Program Integrity Reviews to assess the effectiveness of states’ program integrity efforts, including compliance with federal statutory and regulatory requirements
- Encouraging more states and local partners to participate in the Healthcare Fraud Prevention Partnership (HFPP) along with the existing 41 state and local partners, a number of which are submitting data for cross-payer studies
What's coming...
- Release improvements to the Medicaid Scorecard, including new program integrity measures
- Provide additional Medicaid Managed Care Final Rule program integrity guidance to states, such as reporting overpayments and possible fraud
For more detail, read Administrator Seema Verma's blog post.
With this historic growth comes a commensurate and urgent responsibility by CMS on behalf of the American taxpayers to ensure sound stewardship and oversight of our program resources.
-Seema Verma, Administrator, Centers for Medicare & Medicaid Services
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Page Last Modified:
11/19/2019 03:22 AM