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Program Integrity

The Centers for Medicare & Medicaid Services (CMS) is committed to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid enrollees.

CMS has broad responsibilities under the Medicaid Integrity Program to:

  • Hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issues
  • Provide effective support and assistance to states in their efforts to combat Medicaid provider fraud and abuse
  • Eliminate and recover improper payments in accordance with the Improper Payments Information Act of 2002, Executive Order 13520 and the Improper Payments Elimination and Recovery Act of 2010

For additional general information you can also use the following links to directly access information about the topics listed below.

Enhanced Medicaid Program Integrity Strategy

As part of CMS’s plan to reform Medicaid using the three pillars of flexibility, accountability and integrity, we are announcing a new strategy to ensure we are keeping the Medicaid program sustainable for our future. This strategy is designed to improve Medicaid program integrity through greater transparency and accountability, strengthened data, and innovative and robust analytic tools. These steps are essential to help strengthen and preserve the foundation of the program for the millions of Americans who depend on Medicaid’s safety net.

Comprehensive Medicaid Integrity Plan (CMIP)

The CMIP is developed in consultation with key stakeholders and details the Medicaid Integrity Program's 5-year comprehensive strategy for combating fraud, waste, and abuse.

COMPREHENSIVE MEDICAID INTEGRITY PLAN (CMIP)

Report to Congress

An annual report to Congress on the use and effectiveness of the funds appropriated for the Medicaid Integrity Program.

REPORT TO CONGRESS 

Provider Audits

Section 1936 of the Social Security Act obligates the CMS to procure contractors to audit Medicaid claims and identify overpayments. To fulfill this statutory requirement, the Medicaid Integrity Program (MIP) has procured Audit Medicaid Integrity Contractors (Audit MICs) to conduct provider audits throughout the country.

PROVIDER AUDITS 

National Correct Coding Initiative (NCCI) in Medicaid

The CMS NCCI promotes national correct coding methodologies and reduces improper coding which may result in inappropriate payments of Medicare Part B claims and Medicaid claims.

NATIONAL CORRECT CODING INITIATIVE (NCCI) IN MEDICAID

Medicaid Guidance Fraud Prevention

Best practices and performance standards for states to use in their fraud prevention efforts.

MEDICAID INTEGRITY PROGRAM

State Program Integrity Reviews

Through these triennial reviews, CMS assesses the effectiveness of the state's program integrity efforts, including its compliance with federal statutory and regulatory requirements. The reviews also assist in identifying effective state program integrity activities which may be considered particularly noteworthy and shared with other states.

STATE PROGRAM INTEGRITY REVIEWS 

Medicaid Integrity Institute (MII)

The mission of the MII is to provide effective training, tailored to meet the ongoing needs of state Medicaid program integrity employees, with the goal of raising national program integrity performance standards and professionalism.

MEDICAID INTEGRITY INSTITUTE (MII)

State Program Integrity Assessment (SPIA)

The State Program Integrity Assessment (SPIA) is the CMS first national data collection on state Medicaid program integrity activities for the purposes of program evaluation and technical assistance support. CMS will use the data from the SPIA to develop descriptive reports for each state, identify areas to provide states with technical support and assistance, and assess states' performance over time.

STATE PROGRAM INTEGRITY ASSESSMENT (SPIA) 

Tamper Resistant Prescriptions

All written prescriptions for outpatient drugs prescribed to a Medicaid beneficiary must be on paper that meets all three baseline characteristics of tamper-resistant pads.

TAMPER RESISTANT PRESCRIPTIONS 

Program Integrity (PI) Review Report List

Comprehensive state PI review reports (and respective follow-up review reports) provide CMS' assessment of the effectiveness of the state's PI efforts, including its compliance with federal statutory and regulatory requirements. They also assist in identifying effective state PI activities which may be noteworthy and shared with other states. Focused PI review reports provide information on reviews conducted to examine specific areas of PI concern in one or more states.

PROGRAM INTEGRITY (PI) REVIEW REPORT LIST 

Provider Screening and Enrollment

A critical provision within the Patient Protection and Affordable Care Act (ACA), enacted on March 23, 2010), as amended by the Health Care and Education Reconciliation Act of 2010, enacted on March 30, 2010) is Section 6401(a) of the ACA, and Section 1866(j) of the Social Security Act (the Act). CMS implemented these requirements with federal regulations at 42 CFR Part 455 subpart E. These regulations were published in the Federal Register, Vol. 76, February 2, 2011, and were effective March 25, 2011. This regulation, at 42 CFR 455, requires that all participating providers be screened according to their categorical risk level, upon initial enrollment and upon re-enrollment or revalidation of enrollment. States must submit a State plan amendment (SPA) to CMS for review and approval by April 1, 2012 to provide assurances that they will comply with the Federal regulations at 42 CFR 455 Subpart E. Also, see relevant guidance on Provider Terminations.

PROVIDER SCREENING AND ENROLLMENT