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Medicaid Guidance Fraud Prevention

The Centers for Medicare & Medicaid Services' (CMS) Medicaid Integrity Program provides technical assistance and support to the states by initiating many projects, developing numerous products, and conducting program integrity training  – all designed to provide guidance and tools to the states in order to perform their jobs more efficiently and effectively.

Guidance to States:

  • FAQ on Allowability of Using National Provider Identifiers (NPI) for Medicaid Person Care Attendants (PCAs) – In response to states' requests for guidance, CMS has posted Frequently Asked Questions (FAQ) regarding whether state Medicaid programs may use the NPI to enumerate individual Medicaid PCAs.
  • Vulnerabilities and Mitigation Strategies in Medicaid Personal Care Services (NEW) – The CMS Medicaid Integrity Institute (MII) held a course in early February 2017 to assemble a body of experts to discuss vulnerabilities in Medicaid Personal Care Services (PCS) and develop more effective mitigation strategies.  This paper provides a compendium of the consensus recommendations developed by MII participants to help states more effectively ensure beneficiary safety and prevent improper Medicaid payments in PCS.
  • Frequent Findings Toolkits from Program Integrity Reviews (12/22/14) – CMS has developed Toolkits to address frequent findings from CMS’s comprehensive program integrity reviews of State Medicaid Agencies’ program integrity operations and to help states better understand the requirements and improve their compliance with regulations for provider disclosures, federal database checks, and reporting adverse actions taken against providers to HHS-OIG.  You'll find the link on the left navigation bar titled "Frequent Findings Toolkits for Program Integrity Reviews".
  • Medicaid Payment Suspension Toolkit (10/9/14) – The Affordable Care Act provides for suspension of Medicaid payments during any period when there is pending an investigation of a credible allegation of fraud against a Medicaid provider as determined by the state, unless the state determines that good cause exists not to suspend such payments.  To assist states in proper use of payment suspensions, CMS has developed this toolkit which compiles answers to frequently asked questions and outlines factors to consider if a state believes the payment suspension will create an access to care issue.
  • Data Analytic Capabilities Assessment for Medicaid Program Integrity (toolkit - 9/22/14) - provides guidance to states to assess their own state’s readiness and capability to introduce predictive modeling into their program integrity environments and to become better consumers of, and guide stakeholder discussion about, data analytics and predictive modeling products for program integrity purposes.  The use of data analytics and predictive modeling in the detection of fraud, waste, and abuse in healthcare programs can be a powerful tool for Medicaid program integrity administrators.
  • Best Practices For Medicaid Program Integrity Units' Interactions With Medicaid Fraud Control Units - provides guidance for interactions between State Program Integrity Units (PIUs) and their Medicaid Fraud Control Units (MFCUs) and contains specific examples of actions taken by States that have created well-functioning and committed partnerships between the two entities. (See the Downloads section displayed below.)
  • Performance Standard For Referrals of Suspected Fraud From a Single State Agency To A Medicaid Fraud Control Unit – developed to determine the percentage of acceptable referrals provided by a State Medicaid agency to its MFCU in accordance with 42 CFR 455.21(a)(1). (See the Downloads section displayed below.)
  • Best Practices for Medicaid Program Integrity Units' Collection of Disclosures in Provider Enrollment - provides best practices to strengthen Medicaid provider enrollment and reduce improper payments through effective collection of provider disclosures; and methods to improve policymaking regarding provider enrollment; to comply with provider enrollment regulations; to conduct exclusion searching; and to report adverse provider actions as required by Federal regulations. (See the Downloads section displayed below.)
  • Drug Diversion in the Medicaid Program (National Bulletin, Revised January 2012) - An informative background about drug diversion and what steps are being taken to educate state partners.  Additional information includes strategies for combating controlled prescription drug diversion.  (See the Downloads section displayed below.)
  • Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care - is a product of the National Medicaid Fraud and Abuse Initiative that is intended to provide information to states how to address fraud and abuse in the Medicaid Managed Care environment.  (See the Downloads section below.)