Medicaid Managed Care Plans' Focus on Fraud Referrals

For Medicaid managed care, States contract with private health insurance companies, or managed care plans, that have the primary responsibility for processing, paying, and monitoring the claims of providers in their networks. As such, managed care plans play a critical role in safeguarding Medicaid program integrity. According to Federal regulations, State contracts with managed care plans must require that plans promptly refer any potential fraud, waste, or abuse to State Medicaid agencies or Medicaid Fraud Control Units (MFCUs). However, both OIG and CMS have ongoing concerns about managed care plans' efforts to combat fraud, including concerns about a lack of fraud referrals. This evaluation will determine the number of potential fraud referrals managed care plans made to States, MFCUs, and other entities; determine whether managed care plan processes support the referral of potential fraud; and identify the factors that influence whether managed care plans make referrals. This work may identify ways to increase the total number of managed care plan referrals and ensure the quality and timeliness of referrals.

Announced or Revised	Agency	Title	Component	Report Number(s)	Expected Issue Date (FY)
September 2022	Centers for Medicare and Medicaid Services	Medicaid Managed Care Plans' Focus on Fraud Referrals	Office of Evaluation and Inspections	OEI-03-22-00410	2025