Medicaid program integrity (PI) activities are meant to ensure that taxpayer dollars are spent appropriately on delivering high-quality and necessary care, and preventing and detecting fraud, waste, and abuse. State Medicaid programs have primary responsibility for PI, which includes a wide range of activities, some of which are specific to PI while others are embedded in other program functions. The Centers for Medicare & Medicaid Services (CMS) provides a regulatory framework for Medicaid program integrity in addition to providing routine oversight and technical assistance.
Chapter 3 presents findings from MACPAC’s recent study on how states measure PI performance and return on investment. States have received little guidance on where or how to focus their PI efforts and investments and little is known about which approaches work or why. As the federal Medicaid regulatory and oversight agency, CMS can centralize efforts to help states identify which state-level policy design and implementation approaches lead to successful PI outcomes. The Commission makes two recommendations in Chapter 3: (1) that Secretary of the U.S. Department of Health and Human Services use existing authority to examine states’ current PI activities, conduct pilots to test novel or improved PI strategies, and share these findings with the states; and (2) that Congress amend the law to make the Medicaid recovery audit program optional.
From: June 2019 Report to Congress on Medicaid and CHIP