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State Program Integrity Reviews

State program integrity reviews play a critical role in how CMS provides effective support and assistance to States in their efforts to combat provider fraud and abuse.  The reviews are comprehensive, including examinations of provider enrollment, provider disclosures, program integrity, managed care and the State's relationships with the Medicaid Fraud Control Unit (MFCU). 

Through these reviews, CMS assesses the effectiveness of the State's program integrity efforts, including its compliance with Federal statutory and regulatory requirements.  The reviews also assist in identifying effective State program integrity activities which may be considered particularly noteworthy and shared with other States. (For State program integrity review reports, click on the "Program Integrity Review Reports List" on the Left Navigation Bar.)

CMS also conducts focused program integrity reviews on an as-needed basis.  Focused reviews examine specific areas of program integrity concern in one or more states.

The Program Integrity Review Annual Summary reports each include a compendium of data collected from comprehensive integrity reviews for which final reports have been issued.  Each Program Integrity Review Annual Summary report's title identifies the federal fiscal year reviews included in the report. The report includes information about effective practices, areas of vulnerability and areas of non-compliance.  The Medicaid Integrity Group will publish this report annually in its efforts to provide effective support and assistance to the States.  (For the Program Integrity Review Annual Summary Reports, click on the "Downloads" below.)

CMS developed Frequent Findings 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".