Program Integrity

The Affordable Care Act includes numerous provisions designed to increase program integrity in Medicaid, including terminating providers from Medicaid that have been terminated in other programs, suspending Medicaid payments based on pending investigations of credible allegations of fraud, and preventing inappropriate payment of claims under Medicaid.

Areas of interest under this provision:

Provider Enrollment:  Screening and enrolling providers under requirements to increase program integrity in Medicaid and CHIP

Provider Participation: Terminating the participation of individuals or entities under Medicaid and the Children's Health Insurance Program if they have been terminated under Medicare or any other Medicaid state plan.

Pending Investigations of Credible Allegations of Fraud: Ensuring that federal funding is not provided to individuals or entities when there is a pending investigation of a credible allegation of fraud, unless the state determines that good cause exists not to suspend such payments.

National Correct Coding Initiative (NCCI): Incorporating "NCCI methodologies" in state Medicaid claims processing systems to promote correct coding and control improper coding leading to inappropriate payment of claims under Medicaid.

Recovery Audit Contractors (RACs): Establishing Recovery Audit Contractors (RACs) to audit payments to Medicaid providers. Medicaid RACs will identify and recover provider overpayments and will also identify underpayments.

Home Health: Documenting that a health care provider has had a face-to-face encounter with a patient prior to ordering the provision of home health services.