Resources for SMAs
Resources for State Medicaid Agencies
We have created the resources below to help you successfully manage your state’s Medicaid program integrity activities, train your staff, and educate providers. These resources include best practices on a variety of topics, informative resources about provider requirements, and frequent findings from state program integrity reports. We have also created one-page infographics on relevant topics that are especially useful for training and education.
Infographics
The one-page infographics below provide quick overviews of commonly challenging topics in Medicaid. These infographics can be posted in offices or waiting areas and can be used as part of training and education programs for state staff, providers, or beneficiaries.
Best Practices for State Medicaid Agencies
- Best Practices for Medicaid Program Integrity Units' Collection of Disclosures in Provider Enrollment (PDF)
Best practices to improve provider enrollment policies, collection of provider disclosures, and conducting of exclusion searches. Also covers how to report adverse provider actions. (10 pages) - Best Practices for Medicaid Program Integrity Units' Interactions with Medicaid Fraud Control Units (PDF)
Guidance and best practices for interactions between State Program Integrity Units (PIUs) and their Medicaid Fraud Control Units (MFCUs). (9 pages) - Data Analytic Capabilities Assessment for Medicaid Program Integrity (PDF)
Introduces states to data analytics and predictive modeling products. Helps states assess their readiness to introduce predictive modeling into their program integrity environments. (21 pages) - Performance Standard for Referrals of Suspected Fraud from a Single State Agency to a Medicaid Fraud Control Unit (PDF)
Guidance on how to calculate the percentage of acceptable referrals provided by a State Medicaid agency to its MFCU. (2 pages) - Vulnerabilities and Mitigation Strategies in Medicaid Personal Care Services (PDF)
Best practices to help states more effectively ensure beneficiary safety and prevent improper Medicaid payments in Medicaid Personal Care Services (PCS). (35 pages)
Provider Requirements
We have created the resources below to help states with a range of topics in provider management including enrollment, ownership and control, payments, and more. States can also use these resources to educate providers and improve compliance. Most of the resources are short fact sheets that provide high-level information on topics. We also provide frequent findings from State Program Integrity Reviews on select topics in provider management.
General
- Introduction to Medicaid Fact Sheet (PDF) (2 pages)
- The Role of Brokers in the Medicaid Program Fact Sheet (PDF) (2 pages)
Enrollment
Ownership and Control
- Frequent Findings on Disclosures of Ownership and Control (PDF) (17 pages)
- Fiscal Agents: Disclosure of Ownership and Control Fact Sheet (PDF) (2 pages)
- Frequent Findings on Disclosures of Business Transactions Fact Sheet (PDF) (2 pages)
- Disclosure of Business Transactions with Subcontractors and Wholly Owned Suppliers Fact Sheet (PDF) (2 pages)
- Corporate Integrity Agreements Fact Sheet (PDF) (2 pages)
Criminal Background
- Frequent Findings on Disclosures of Healthcare-Related Criminal Convictions (PDF) (2 pages)
- Sanctions for Provider Misconduct Fact Sheet (PDF) (2 pages)
Payments
Managed Care Toolkits
- Managed Care Payment Suspensions (PDF)
This toolkit discusses managed care-related payments suspensions and the procedures in place to suspend payment when there is credible allegation of fraud, consistent with requirements found in 42 CFR 438.608(a)(8). (10 pages) - Managed Care Overpayment Recoveries (PDF)
This toolkit discusses how recoveries of network provider overpayments may be treated. These regulations provide states with flexibility on how to handle recoveries made by MCPs to create incentives for MCPs to proactively oversee network provider billing practices and identify fraud, waste, and abuse. (11 pages) - Managed Care Fraud Referral (PDF)
This Prompt Referrals of Potential Fraud, Waste, or Abuse Toolkit discusses the requirements of MCPs to promptly report and establish clear timelines for referrals of potential fraud, waste, or abuse to the State Medicaid Program Integrity Unit or Medicaid Fraud Control Unit as required. (8 pages) - Managed Care Compliance (PDF)
This Compliance Program Requirements Toolkit discusses the compliance program requirements that states must follow when entering into contracts with MCPs. (12 pages)
Page Last Modified:
09/10/2024 06:18 PM