Resources for State and Territory Program Integrity Directory

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RESOURCES FOR STATE
AND TERRITORY PROGRAM 
INTEGRITY DIRECTORS
 

We developed a centralized location for program integrity directors to find the resources to be successful in their day-to-day management of their state's or territory's Medicaid program integrity work. These resources include promising practices on a variety of topics, informative resources about provider requirements, and frequent findings from state program integrity reports. We have also created one-page infographics on relevant topics that are useful for training and education.

Do you know of a great resource we should include? Submit it to us at Medicaid_Integrity_Program@cms.hhs.gov.

 

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Quick Guides for Commonly Requested Information

The quick guides below provide commonly requested information by program integrity directors. 

Center for Program Integrity (CPI) Overview Statements

The Secretary of the Department of Health and Human Services (HHS) created the Center for Program Integrity (CPI) to align Medicare and Medicaid activities in March 2010. CPI is organized as 7 Groups and 33 Divisions. The seven groups that make up CPI are: Audits and Vulnerabilities Group, Contract Management Group, Data Analytics & Systems Group, Executive Support Group, Fraud Investigations Group, Provider Compliance Group, and the Provider Enrollment & Oversight Group.

Audits and Vulnerabilities Group (AVG)

AVG conducts program integrity (PI) functions related to Medicare Part C, Medicare Part D, Medicaid, the Children’s Health Insurance Program (CHIP), and the Marketplaces. As part of its oversight work, AVG maintains partnerships with federal and state partners, such as other CMS components, Office of Inspector General (HHS-OIG), Department of Justice (DOJ), Federal Bureau of Investigation (FBI), state Departments of Insurance (DOI), state Attorney Generals (AG), Internal Revenue Service (IRS), Federal Trade Commission (FTC), U.S. Treasury, state-based individual markets among others, as well as collaboration with private plans.

Contract Management Group (CMG)

CMG serves as the primary CPI point of contact for procurement activities, functional administration and oversight of the Medicare and Medicaid program integrity contractors.  CMG is responsible for contract pre-award, contract administration, and contractor performance and assessment.

Data Analytics & Systems Group (DASG)

DASG is responsible for modeling and analytics, investigative systems management, provider systems management, and outcomes measurement. DASG is CMS’ primary focal point for Medicare and Medicaid data analytics and systems related to fraud, waste, and abuse; as such they are responsible for the management and oversight of fourteen systems including National Plan & Provider Enumeration System (NPPES), Open Payments and Provider Enrollment, Chain, and Ownership System (PECOS) to name a few.

 
Division of Modeling & Analytics (DMA)

DMA provides statistical and data analysis for program integrity issues in the Medicaid, original Medicare, Medicare Advantage, and Prescription Drug Plan programs. They are responsible for identifying emerging fraud trends through data mining and other advanced analytical techniques to prevent and detect fraud, waste and abuse in the Medicaid and Medicare programs. DMA also leads the model and edit development for the Fraud Prevention System (FPS).

Executive Support Group (ESG)

Within ESG the Division of Clearance and Correspondence (DCC) along with other CPI groups coordinate the resolution process for the single state audits.  https://www.ecfr.gov/current/title-2/subtitle-A/chapter-II/part-200/subpart-F 

Fraud Investigations Group (FIG)

FIG serves as the primary group within CPI for Medicare and Medicaid investigations. FIG works closely with CMS contractors and law enforcement partners to uncover new healthcare fraud schemes develop investigative strategies to address those fraud schemes and take action to safeguard the Medicare Trust Fund. In addition, FIG also monitors Part D plan sponsor self-audits, oversees Part D overprescribing investigations, and engages in efforts to mitigate the opioid epidemic. To complete this important work, FIG is comprised of four divisions based primarily in the Baltimore region and four field operation divisions that are in strategically important areas of the United States.

 
Division of Field Operations (DFO-North, South, and West)

The Division of Field Operations (DFO) develops FIG national strategies and investigative processes for Medicare and Medicaid and provides technical assistance to Medicaid state program integrity components on audits and investigations for their region. The DFO serves as the Medicaid and Medi-Medi Business Function Lead for CMS unified program integrity contractors (UPICs) and conducts regional program integrity activities in Medicare and Medicaid.

 
Division of Fraud Prevention Partnerships (DFPP)

DFPP implements and supports the technologies, informatics/reporting, and innovative data-exchange tools for the Healthcare Fraud Prevention Partnership. Functions include the development of strategic and operational plans for the necessary technologies and supporting tools required by the program. Designs and implements innovative solutions to improve Medicare and Medicaid related data accuracy to ease stakeholder burden and encourage engagement with the information technology systems and direct the development and maintenance of technical requirements. DFPP also manages the technical aspects of the partnership and its contractors, as well as provides education and training on software capabilities and functionalities. 

Provider Compliance Group (PCG)

PCG coordinates with the Center for Medicare and the Center for Clinical Standards and Quality in the development of contractor medical review policy. PCG is responsible for the planning, development, and implementation of recovery auditing techniques and prior authorization activities in the Medicare fee-for-service program. This group works closely with CMS Centers, Offices, and the Chief Operating Officer to identify and monitor program vulnerabilities and affect changes in policy as necessary.

Provider Enrollment & Oversight Group (PEOG)

PEOG serves as CMS’s primary source for all Medicare provider and supplier enrollment compliance functions. PEOG develops the integrated and coordinated national framework for program integrity related enrollment policy and procedures across the Medicare and Medicaid programs. Some of PEOG duties include making determinations on provider and supplier adverse action requests, including revocations, and deactivations; developing budget guidelines, cost estimates, and processing guidelines for Medicare provider and supplier enrollment activities; and maintaining definitive record of providers and suppliers enrolled in Medicare, and enforces compliance.

 
Division of Quality & Compliance (DQC)

DQC is responsible for developing enrollment policies and procedures across the Medicaid program and working with State Medicaid programs and other stakeholders on provider enrollment and program integrity related issues. DQC maintains and renews Interagency Agreements as it relates to provider enrollment and oversees the contracts for the Data Exchange System (DEX) and Indefinite Delivery Indefinite Quantity (IDIQ), including NPE (East & West), National Site Visit Contractor, the National Fingerprinting contractor, the Provider Ownership Verification (POV) contractor, and the Adverse Legal Action (ALA) contractor. In addition, DQC oversees the process of identifying and reporting provider enrollment related vulnerabilities and ensuring implementation of necessary policies directed at preventing fraud and abuse and to improve administrative efficiencies in Medicare and Medicaid enrollment of providers and suppliers. DQC develops, launches, and manages an enhanced collection, storage, and delivery process for Medicaid termination notifications through the DEX and is responsible for reviewing Medicaid Termination submissions. 

The CMS organizational chart can be found at: 
https://www.cms.gov/about-cms/who-we-are/organizational-chart.

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CPI Resource Email Contacts

CPI supports state Medicaid agencies’ efforts to enhance and strengthen the integrity of their programs.  To support this need, the following shared resource mailboxes are available to support different areas related to Medicaid program integrity. 

Medicaid_Integrity_Program@cms.hhs.govThis resource box is used to receive all inquiries and/or requests related to Medicaid program integrity.
PERMCAPS@cms.hhs.govThis resource box is used to receive all inquiries and/or requests related to Payment Error Rate Measurement (PERM) Corrective Action Plans (CAPs).
CMS-MEQC-Inquiries@cms.hhs.govThis resource box is used to receive all inquiries and/or requests related to Medicaid Eligibility Quality Control (MEQC) program.
MIIResource@cms.hhs.govThis resource box is used to share MII course announcements, nominations, and acceptances, as well as receive all inquiries and/or requests related to the MII program.
MedicaidProviderEnrollment@cms.hhs.govThis resource box is used to receive all Medicaid provider enrollment and termination inquiries.

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Fraud, Waste, and Abuse Technical Advisory Group (FWA-TAG)

The FWA-TAG exists as a forum for sharing issues, solutions, resources, and experiences among the states and territories to develop best practices; provide input to CMS based on state experience related to implementation of CMS policies, procedures, and program development.

The FWA-TAG's primary partners are CMS (Medicaid) and all state and territory Medicaid programs; however, Medicaid Fraud Control Units (MFCU) and other federal and state enforcement agencies are pivotal to the success of the FWA-TAG's efforts.

The FWA-TAG serves as a joint forum among state/territory and federal partners to develop and implement methods of reducing or eliminating fraud and abuse in the Medicaid program and does this by developing beneficial relationships, broadening participation, and gathering input from all stakeholders and customers.  The FWA-TAG then shares this information and recommendations with its partners and stakeholders.

Membership of the Official FWA-TAG

Regional representation is a priority for composition of the FWA-TAG.  Representation is based on one state or territory employee from each of CMS' ten regions.  Additionally, there is a chairperson. Program integrity (PI) employees of each state may also participate on the monthly calls. 

Chair:   Member of the PI community identified by CMS.

 

Region 1 - ME, NH, VT, MA, CT, RI 

Region 2 - NY, NJ, Puerto Rico, Virgin Islands

Region 3 - PA, WV, MD, VA, DE, DC 

Region 4 - FL, GA, KY, TN, NC, SC, MS, AL 

Region 5 - IL, WI, MN, MI, OH, IN 

Region 6 - TX, NM, OK, AR, LA 

Region 7 - NE, IA, KS, MO

Region 8 - CO, UT, WY, MT, ND, SD

Region 9 - CA, NV, AZ, HI, Commonwealth of the Northern Mariana Islands, Guam, American Samoa

Region 10 - WA, OR, ID, AK

The FWA-TAG meets monthly on the third Tuesday via conference call for ALL state and territory program integrity directors and their staff.  There are also sub-group TAG calls. Participating in the FWA-TAG is a great way to receive updates and is a tool for states and territories to pose questions to their peers to address challenges they are facing and share successes.

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Sub-Groups of the FWA-TAG

Small States TAG call (monthly):  Established to bring small states (based on Medicaid budget and Medicaid population size) together to address specific areas and concerns that small states and the territories encounter that may not be as relevant to larger states with larger resources.  Typically, program integrity directors and staff attend. The small states and territories are Alaska, American Samoa, Commonwealth of the Northern Mariana Islands, Delaware, District of Columbia, Guam, Hawaii, Idaho, Indiana, Maine, Montana, Nebraska, Nevada, New Hampshire, North Dakota, Puerto Rico, Rhode Island, South Dakota, Utah, Vermont, Virgin Islands, West Virginia, and Wyoming.
 

Provider Enrollment TAG call (monthly): For ALL states to discuss provider enrollment needs, concerns, regulations, etc.  Typically, both program integrity and provider enrollment staff attend.
 

Data Analytics TAG call (monthly): For ALL states to discuss data analytics pertaining to fraud, waste and abuse algorithms, successes, and more.  Typically, data and statistical program integrity staff attend.
 

Beneficiary Fraud TAG call (monthly):  For ALL states and territories to come together to discuss beneficiary Medicaid eligibility and fraud concerns.  States and territories bring challenges, successes, and questions to address preventing and combating Medicaid beneficiary eligibility fraud.  Typically, program integrity directors and beneficiary fraud staff and occasional eligibility and enrollment staff attend this call.
 

To join any TAG, submit a request to Medicaid_Integrity_Program@cms.hhs.gov.

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Resource Materials

     Statutes, Regulations, and Sub-Regulatory Guidance

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Page Last Modified:
01/16/2025 09:05 AM