State Program Integrity Reviews
Guidance for State Program Integrity Reviews and their annual summary reports.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 10, 2020
Medicaid and the Children's Health Insurance Program (CHIP) are required to have a fraud detection and investigation program that meets certain federal standards. To assist the states with these requirements, CMS offers the Medicaid Program Integrity Manual.
To help oversee this requirement, CMS conducts focused program integrity reviews on high-risk areas in the Medicaid program:
- Case tracking and referrals
- Managed care
- New statutory and regulatory compliance
- Overpayment identification and recovery
- Personal Care Services
- Pre-payment and post-payment review
- Surveillance and utilization systems
- Territory oversight operations
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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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.