{"database": "openregs", "table": "crs_reports", "rows": [["IF13326", "Medicaid Program Integrity: Background and Resources", "2026-10-07T04:00:00Z", "2026-10-09T14:23:34Z", "Active", "Resources", "Angela Napili, Sarah K. Braun, Alison Mitchell", "Medicaid & CHIP", "Medicaid is a means-tested entitlement program that finances the delivery of primary and acute medical services, as well as long-term services and supports (LTSS). Each state designs and administers its own Medicaid program within federal parameters. In FY2024, Medicaid covered health care services for an estimated 85 million individuals at an estimated cost of $949 billion.\nAt the federal level, the Centers for Medicare & Medicaid Services (CMS) approves Medicaid state plan amendments and waivers. Both the states and the federal government are responsible for Medicaid program integrity activities to ensure that all federal and state Medicaid rules are followed. For further background on Medicaid, see CRS In Focus IF10322, Medicaid Primer, and CRS Report R43357, Medicaid: An Overview.\nThis In Focus provides background information on key questions about Medicaid program integrity and identifies selected supplemental federal resources.\nWhat Is Program Integrity?\nMedicaid program integrity activities are those administrative activities that ensure that the state Medicaid programs, Medicaid providers, and Medicaid enrollees operate in accordance with the federal and state Medicaid laws. \nOften, Medicaid program integrity activities are associated with the identification and prevention of fraud, waste, and abuse. While these are core program integrity activities, program integrity also encompasses additional components, such as oversight of the Medicaid program and identifying improper payments and overpayments. \nProgram integrity activities also include measuring improper payments through the Payment Error Rate Measurement (PERM) program. An improper payment is \u201cany payment that should not have been made or that was made in an incorrect amount (including overpayments and underpayments) under statutory, contractual, administrative, or other legally applicable requirements\u201d (42 C.F.R. \u00a7431.958). CMS estimates that most improper payments (77% in FY2025) are the result of insufficient documentation (e.g., failing to submit documentation for a Medicaid enrollee who is eligible for the medical service) rather than fraud or abuse. \nAdditional program integrity activities include oversight of state Medicaid agencies, managed care entities, health care providers, and Medicaid enrollees to ensure that federal and state Medicaid laws are being followed.\nThe total amount of Medicaid fraud is unknown. State Medicaid Fraud Control Units (MFCUs) reported recovering $2 billion from criminal and civil cases in FY2025. CMS reported that program integrity activities for Medicaid and the Children\u2019s Health Insurance Program (CHIP) saved the federal government $1.5 billion in FY2024.\nDefinitions of Fraud, Waste, and Abuse\nThe words fraud, waste, and abuse are often connected in one phrase, but these are three distinct concepts. According to CMS, \u201cThe difference depends on circumstances, intent, and knowledge\u201d:\nFraud is the \u201cintentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person\u201d (42 C.F.R \u00a7455.2). \nWaste has been described as \u201coverusing services or other practices that directly or indirectly result in unnecessary costs to any health care benefit program. Examples of waste are conducting excessive office visits, prescribing more medications than necessary, and ordering excessive laboratory tests\u201d (CMS).\nAbuse is \u201cprovider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care\u201d (42 C.F.R. \u00a7455.2).\n\nWho Is Responsible for Program Integrity?\nMedicaid program integrity activities involve a multifaceted approach including multiple federal and state agencies.\nFederal Program Integrity Activities \nThe federal agencies involved in Medicaid program integrity include CMS, the Department of Health and Human Services\u2019 Office of the Inspector General (HHS OIG), and the Department of Justice (DOJ). The federal government oversees states\u2019 administration of their Medicaid programs, audits Medicaid programs, administers the PERM program, and investigates and prosecutes cases of Medicaid fraud. CMS administers the Medicaid Integrity Program, which audits and monitors state Medicaid programs and supports state program integrity efforts. HHS OIG has broad program integrity enforcement, audit, and evaluation authority for HHS programs, including Medicaid. DOJ investigates and prosecutes Medicaid fraud cases and coordinates federal, state, and local law enforcement.\nState Program Integrity Activities\nState Medicaid programs are also required to conduct several program integrity activities. States\u2019 program integrity responsibilities include screening providers and suppliers before they enroll in state Medicaid programs. States are also required to operate MFCUs, generally through state attorney general offices. MFCUs are responsible for investigating fraud as well as patient abuse and neglect in facilities that receive state Medicaid payments. States are also required to contract with recovery audit contractors (RACs) \u201cfor the purpose of identifying underpayments and overpayments and recouping overpayments.\u201d In addition, states with Medicaid managed care are required to conduct independent audits of the managed care financial and encounter data.\nWhat Federal Sources Provide Medicaid Program Integrity Information?\nBelow are selected federal resources that provide information about Medicaid program integrity. State Medicaid websites may have additional resources.\nCenters for Medicare & Medicaid Services (CMS)\nCMS has multiple initiatives that provide information on program integrity efforts.\nThe Medicaid Integrity Program reports on its oversight and education activities, including within\nthe Comprehensive Medicaid Integrity Plan, \nannual reports to Congress on Medicaid and Medicare program integrity programs, and\nstate program integrity reviews.\nThe Medicaid Federal Policy Guidance database includes CMS guidance to states on the implementation of laws, policy issues, and technical assistance. Users can search by topic, such as program integrity. \n\u201cCrushing Fraud, Waste, & Abuse\u201d profiles CMS initiatives such as the Fraud Defense Operations Center (also known as the Medicaid Fraud War Room) and Medicaid High-Risk Services Spotlights.\nThe CMS Newsroom has press releases on program integrity initiatives. Users can limit search results using the \u201cfraud, waste, and abuse\u201d tag.\nDepartment of Health and Human Services, Office of Inspector General (HHS OIG)\nAmong its program integrity responsibilities, HHS OIG conducts Medicaid audits, excludes providers from the Medicaid program, and exercises oversight of Medicaid, including state MFCUs.  \nHHS OIG has issued numerous Medicaid reports. See also \u201cEnforcement Actions,\u201d \u201cRecommendations,\u201d and \u201cTop Unimplemented Recommendations\u201d limited to Medicaid.\nThe HHS OIG page on MFCUs provides information and resources on program requirements and standards (e.g., statutes and regulations, policy guidance), MFCU activities and OIG oversight (e.g., MFCU reports, OIG annual reports, state enforcement actions, and MFCU certification letters), and other resources (e.g., directory of MFCU directors).  \nMedicaid and CHIP Payment and Access Commission (MACPAC)\nMACPAC is a nonpartisan legislative branch agency that provides policy and data analysis. Resources include \n\u201cMedicaid Program Integrity\u201d (April 2026), which describes measures of fraud, waste, and abuse; summarizes the program integrity roles of federal agencies, states, and health plans; and discusses key issues in managed care and in federal investigations, assistance, and oversight; and\n\u201cKey Legislative Milestones and Statutory Provisions in Program Integrity.\u201d \nDepartment of Justice (DOJ)\nAmong its program integrity responsibilities, DOJ investigates and prosecutes Medicaid fraud cases and coordinates federal, state, and local law enforcement.\nThe DOJ National Fraud Enforcement Division\u2019s Health Care Fraud Section includes examples of enforcement actions and strike force operations. \nDOJ press releases highlight examples of Medicaid fraud cases.\nHHS-DOJ Health Care Fraud and Abuse Control Program (HCFAC)\nJointly directed by the Attorney General and the HHS Secretary, HCFAC coordinates federal, state, and local health care law enforcement activities.\nHCFAC annual reports highlight significant investigations, activities, and monetary results.\nGovernment Accountability Office (GAO)\nGAO is a nonpartisan legislative branch agency that examines federal programs. \nThe GAO High Risk List is updated at the start of each new Congress and has \u201cprograms and operations with serious vulnerabilities to waste, fraud, abuse, or mismanagement, or in need of transformation.\u201d \u201cStrengthening Medicaid Program Integrity\u201d is on the most recent list (February 2025).\nGAO publishes reports and testimonies on various topics, including Medicaid program integrity. Users can search by keyword and filter by date, topic, or agency. ", "https://www.congress.gov/crs_external_products/IF/PDF/IF13326/IF13326.2.pdf", "https://www.congress.gov/crs_external_products/IF/HTML/IF13326.html"]], "columns": ["id", "title", "publish_date", "update_date", "status", "content_type", "authors", "topics", "summary", "pdf_url", "html_url"], "primary_keys": ["id"], "primary_key_values": ["IF13326"], "units": {}, "query_ms": 0.2050548791885376, "source": "Federal Register API & Regulations.gov API", "source_url": "https://www.federalregister.gov/developers/api/v1", "license": "Public Domain (U.S. Government data)", "license_url": "https://www.regulations.gov/faq"}