Medicaid and the Children’s Health Insurance Program (CHIP) are required to have a fraud detection and investigation program that meets certain federal standards. To assist the states with these requirements, CMS offers the Medicaid Program Integrity Manual.
To help oversee this requirement, CMS conducts focused program integrity reviews on high-risk areas in the Medicaid program:
- Case tracking and referrals
- Managed care
- New statutory and regulatory compliance
- Overpayment identification and recovery
- Personal Care Services
- Pre-payment and post-payment review
- Surveillance and utilization systems
- Territory oversight operations
In addition to the focused reviews, CMS conducts desk reviews of states’ program integrity activities, which allows CMS to conduct oversight of additional states each year. Desk reviews are less complex because they focus on other areas of concern, such as the progress of states’ corrective actions, an evaluation of states’ compliance with broader program integrity regulations, reviews of service areas such as Non-Emergency Medical Transportation (NEMT) and telehealth, and best practices to share with other states.
Focused Program Integrity Review Reports
CMS conducts focused reviews to assess the state’s program integrity oversight efforts of high-risk areas. These reviews specifically assess the state’s compliance with CMS regulatory requirements. A secondary objective of this review is to provide the state with feedback, technical assistance, and educational resources that may be used to enhance program integrity in the delivery of high-risk areas. At the conclusion of the reviews, CMS incorporates states’ feedback and makes the reports available.
To assist the state in strengthening its program integrity operations, CMS also offers technical assistance, educational resources, and best practices at https://www.cms.gov/medicare/medicaid-coordination/states.