Program Integrity Pillars for Medicaid and the Children’s Health Insurance Program (CHIP)

CMS and States face evolving and emerging threats to the integrity of the Medicaid program and Children’s Health Insurance Program (CHIP). These risks and vulnerabilities misuse taxpayer resources, lead to beneficiary harm, and threaten the longevity of these critical programs.  Federal data analytics, audits, and investigations have identified billions of dollars in improper payments due to fraud, waste, and abuse. At the state level, stakeholders have reported gaps in coordination across departments responsible for addressing increasingly complex program integrity risks. Providers have also raised concerns about the influence of bad actors on public trust while beneficiaries across the country are vulnerable to poor-quality care.  

CMS and States have important obligations to strengthen program integrity safeguards to crush fraud, waste, and abuse in Medicaid and CHIP. CMS’ Medicaid and CHIP Program Integrity (PI) Pillars reflect CMS’ expectations of the oversight mechanisms that should be in place among the State Medicaid Agencies, managed care plans (MCPs), and law enforcement partners to reflect a first-in-class program integrity continuum in Medicaid and CHIP. The six PI Pillars serve as a comprehensive framework to strengthen program integrity practices and oversight infrastructure: (1) Claims Editing & Data Analytics, (2) Provider Enrollment, (3) Targeted Reviews & Audits, (4) Managed Care Oversight, (5) Investigations & Law Enforcement Referrals; and (6) Robust Administrative Actions. This framework includes actionable guidance and best practices that will enable states and their program integrity partners to more proactively safeguard taxpayer resources, protect beneficiaries, and strengthen Medicaid and CHIP program integrity. 

Claims Editing & Data Analytics

Claims Editing & Data Analytics best practices support states in early detection of fraud, waste, and abuse, and help prevent improper payments before they are made. Key tools include the National Correct Coding Initiative (NCCI) for standardized coding edits, the Healthcare Fraud Prevention Partnership (HFPP), and the Medicaid Emerging Vulnerability Intelligence and Actions (MEVIA) dashboard for cross-payer data sharing and analytics. Additionally, CMS's fraud resource hub highlights high-risk services in Medicaid through heat map illustration that depicts the kind of analyses states can build toward using tools like MEVIA and HFPP. 

• Healthcare Fraud Prevention Partnership (HFPP)
• National Correct Coding Initiative (NCCI)

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Provider Enrollment

Provider Enrollment is the pillar that determines which providers may participate in the Medicaid program, making it the first line of defense against fraud, waste, and abuse. Our guidance covers best practices across several key tools and processes: the Medicaid Provider Enrollment Compendium (MPEC), CMS's reference for building a compliant enrollment and screening program; data exchange and data compare processes, which check providers and owners against federal and state exclusion, sanction, and licensure sources both at enrollment and on an ongoing basis; and the use of National Provider Identifiers (NPIs) for Medicaid Personal Care Attendants (PCAs). 

• Medicaid Provider Enrollment Compendium (MPEC)
• NPIs for Medicaid Personal Care Assistants (PDF)
• Data Exchange (DEX) State User Manual (PDF)
• Data Compare Upload Instructions for State Medicaid Agencies (PDF)
• Data Compare FAQs (PDF)

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Targeted Reviews & Audits

Targeted reviews and audits direct limited resources toward the providers, services, and claims most likely to involve fraud, waste, or abuse. These may occur on either a prepayment or post-payment basis, depending on the risk involved. This pillar works alongside states’ other program integrity functions: it draws on claims editing and data analytics to identify where risk is concentrated, informs provider enrollment and managed care oversight, results in administrative actions and overpayment recoveries, and generates the leads that feed investigations and law enforcement referrals.

Additional guidance forthcoming.

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Managed Care Oversight

As Medicaid managed care has grown to cover the majority of enrollees in most states, Managed Care Oversight has become one of the most consequential pillars of program integrity. Our below guidance provides best practices across five key areas: compliance, overpayment recoveries, payment suspensions, program integrity staffing ratios, and contract language. 

• Managed Care Compliance Toolkit
• Managed Care Overpayment Recoveries Toolkit (PDF)
• Managed Care Payment Suspensions Toolkit

 

Additional guidance forthcoming.

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Investigations & Law Enforcement Referrals

Investigations & Law Enforcement Referrals turns the detection of suspected fraud, waste, and abuse into coordinated action. The guidance below outlines best practices for coordination between the state Medicaid agency and the Medicaid Fraud Control Unit (MFCU) and implementing Medicaid Fraud War Rooms at the state level.

• State Medicaid Fraud War Room
  • Standard Operating Procedure (SOP) (PDF)
  • Sample Agenda (PDF)
  • Exclusion Referral (PDF)
  • Case Presentation Brief (PDF)
  • Data Request Form (PDF)
  • Provider Action Log
• Fraud Referrals Toolkit (PDF)
• MFCU Coordination (PDF)

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Robust Administrative Actions

From payment suspensions and overpayment recovery to provider termination and exclusion, robust administrative actions give states the tools to swiftly respond to fraud, waste, and abuse. States should ensure there is a full suite of administrative actions at its disposal that is grounded in statutory and regulatory support.

Additional guidance forthcoming.

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