Reports & Guidance
Reports & Guidance
Find resources to help you understand the ins and outs of CMS’ program integrity efforts, and read the annual reports that we submit to Congress about our center and our programs.
Reports to Congress
Medicare and Medicaid Integrity Programs
Read the annual reports of CMS' efforts, through the Center for Program Integrity, to combat fraud, waste and abuse of the Medicare, Medicaid and Marketplace programs.
Open Payments Program
Read annual overviews of the Open Payments program and payments reported by applicable manufacturers and group purchasing organizations to physicians and teaching hospitals.
Healthcare Fraud Prevention Partnership
Read the biennial report on the Healthcare Fraud Prevention Partnerships efforts to identify fraud, waste, and abuse across the healthcare sector through collaboration, data and information sharing, and cross-payer research studies.
Medicaid Program Integrity Reports
Comprehensive Medicaid Integrity Plan, FY 2019 - FY 2023 (PDF)
Explore the 5-year, comprehensive plan to protect taxpayer dollars in the Medicaid program by combatting fraud, waste and abuse.
Beneficiary Eligibility Audits
As part of the Comprehensive Medicaid Integrity Plan for FYs 2019-2023 and the Medicaid Program Integrity Strategy, CMS is conducting beneficiary eligibility audits. The primary goal of these audits is to confirm that states’ Medicaid and Children’s Health Insurance Program (CHIP) beneficiary eligibility determinations are appropriate and that the federal match is correctly assessed.
Completed Medicaid and CHIP beneficiary eligibility audit reports are included below:
- New York Medicaid Beneficiary Eligibility Determinations (PDF)
- Kentucky Medicaid Beneficiary Eligibility Determinations (PDF)
- Louisiana Medicaid Beneficiary Eligibility Determinations (PDF)
- Pennsylvania Medicaid and CHIP Beneficiary Eligibility Determinations (PDF)
- Connecticut Medicaid and CHIP Beneficiary Eligibility Determinations (PDF)
- Kansas Medicaid and CHIP Beneficiary Eligibility Determinations (PDF)
- Missouri Medicaid and CHIP Beneficiary Eligibility Determinations (PDF)
Medical Loss Ratio (MLR) Audits
A key component of CMS' managed care program integrity work is to conduct targeted audits of selected states' Medicaid Managed Care Plans' (MCPs) financial reporting. As part of this effort, CMS conducts audits of states' Medicaid MCPs MLR reporting to determine if MCPs submitted annual MLR reports to the state in accordance with federal requirements, and that annual MLR reporting and remittance calculations for the MCPs were supported by the underlying data and supporting documentation received by the state.
Completed MLR audit reports are included below:
- California Medical Loss Ratio Examination Report (PDF)
- Oregon Medicaid Managed Care Medical Loss Ratio Audit Report (PDF)
State Program Integrity Review Reports, 2007 – 2019
This page describes the state program integrity (PI) review reports, and respective follow-up review reports, that provide CMS' assessment of the effectiveness of States' Medicaid PI efforts, including compliance with Federal statutory & regulatory requirements.
Stay Up to Date with CPI
Connect with CPI as we host or attend various events throughout the year, join our mailing list to stay informed on Program Integrity news, or find the most appropriate vehicle to report suspected fraud, waste, or abuse.
Page Last Modified:
09/25/2024 02:33 PM