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Medicaid is Using Prevention and Data-Mining to Fight Fraud

CMS is committed to combating Medicaid provider fraud, waste and abuse, and is using educational resources and state-of-the-art methods to do so. A major purpose of CMS Program Integrity efforts is to ensure that correct payments are made to legitimate Medicaid (and Medicare) providers for covered services that are appropriate and reasonable for eligible beneficiaries. Medicaid fraud involves the intentional deception and diversion of Medicaid resources from health care to an illicit purpose. Funds stolen from the Medicaid program are not available to pay for health care services that program beneficiaries need. Learn more about CMS program integrity activities

With the help of new tools provided by the Affordable Care Act, the Medicaid program, like Medicare, has shifted toward a “prevent and detect” strategy. Before a new provider is allowed to enroll in a state Medicaid program and bill for services, the provider is screened to help ensure that the program would not be at risk for fraud if the provider were allowed to enroll. In addition, state agencies periodically revalidate the enrollment of all of their existing providers to ensure that they continue to be eligible. The revalidation includes verifying that providers remain properly licensed, have not been excluded from federal health care programs, and do not have criminal records relating to health care. Screening both newly enrolling and currently enrolled providers helps state Medicaid agencies keep bad actors out of the program and limit losses resulting from fraud. In addition, state Medicaid agencies are using new data- mining techniques, such as predictive analytics to identify aberrant billing practices as they develop. Learn more about how “predictive analytics” is helping to fight fraud in both Medicaid and Medicare. 

CMS is offering links/charts for informational purposes only, facts should not be construed as an endorsement of the organization's programs or activities

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