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Medicaid Guidance Fraud Prevention

The Centers for Medicare & Medicaid Services' (CMS) Medicaid Integrity Program provides technical assistance and support to the states by initiating many projects, developing numerous products, and conducting program integrity training – all designed to provide guidance and tools to the states in order to perform their jobs more efficiently and effectively.


Guidance to States:


Best Practices For Medicaid Program Integrity Units' Interactions With Medicaid Fraud Control Units provides guidance for interactions between State Program Integrity Units (PIUs) and their Medicaid Fraud Control Units (MFCUs) and contains specific examples of actions taken by States that have created well-functioning and committed partnerships between the two entities.

Performance Standard For Referrals of Suspected Fraud From a Single State Agency To A Medicaid Fraud Control Unit was developed to determine the percentage of acceptable referrals provided by a State Medicaid agency to its MFCU in accordance with 42 CFR 455.21(a)(1).

Best Practices for Medicaid Program Integrity Units' Collection of Disclosures in Provider Enrollment provides best practices to strengthen Medicaid provider enrollment and reduce improper payments through effective collection of provider disclosures; and methods to improve policymaking regarding provider enrollment; to comply with provider enrollment regulations; to conduct exclusion searching; and to report adverse provider actions as required by Federal regulations.