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

Read About Milestones & Priorities
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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.
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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
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Data Sharing & Partnerships
What We're Doing...
What's Coming...
  • Conduct provider screening on behalf of states for Medicaid-only providers
Icon Depicting Education, Technical Assistance, and Collaboration
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

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:
07/13/2020 11:24 AM