State Program Integrity Reviews
Guidance for State Program Integrity Reviews and their annual summary reports.
Final
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 10, 2020
State Program Integrity offices are on the front line of the fight to combat fraud, waste, and abuse in Medicaid. The Centers for Medicare & Medicaid Services (CMS) supports those efforts with regular state level reviews. From 2007-2013 CMS conducted comprehensive reviews of each state’s Medicaid Program Integrity (PI) activities and reported findings and recommendations to states. The comprehensive reviews involved an in-depth assessment of the state’s PI activities:
- Regulatory compliance
- Surveillance and utilization systems
- Case tracking
- Pre-payment and post-payment review
- Provider enrollment and disclosures
- Interactions with the state's Medicaid Fraud Control Unit (MFCU)
- Oversight of managed care operation
As a companion to the comprehensive reviews, CMS created Frequent Findings reports. These toolkits were designed to help states better understand requirements and improve compliance with regulations for provider disclosures, federal database checks, and reporting adverse actions taken against providers to HHS-OIG.
Beginning in 2014, CMS began conducting focused reviews. Focused reviews are conducted to determine the extent of program integrity (PI) oversight of the Medicaid program by the States. Traditionally, these reviews have focused on high risk areas of managed care, Affordable Care Act provisions, personal care services and non-emergency medical transportation.
These reviews are designed to identify risks and vulnerabilities to the Medicaid program and assist states with strengthening program integrity operations. The significance and value of performing onsite program integrity reviews include:
- Assess the effectiveness of the state’s PI efforts, including compliance with certain Federal statutory and regulatory requirements
- Identify risks and vulnerabilities to the Medicaid program and assist states to strengthen PI operations
- Help inform CMS in developing future guidance to states
- Help prepare states with the tools to improve PI operations and performance
Annual Summary Reports
- 2013 Program Integrity Review Annual Summary Report (PDF)
- 2012 Program Integrity Review Annual Summary Report for FYs 2010 & 2011 (PDF)
- 2011 Program Integrity Review Annual Summary Report for FYs 2009 & 2010 (PDF)
- 2010 Program Integrity Review Annual Summary Report for FYs 2008 & 2009 (PDF)
- 2009 Program Integrity Review Annual Summary Report for FYs 2007 & 2008 (PDF)
Search below for comprehensive and focused reports by state or year.
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