About Program Integrity

CENTER FOR PROGRAM INTEGRITY

PROTECTING THE MEDICARE & MEDICAID PROGRAMS FROM FRAUD, WASTE & ABUSE

The Centers for Medicare & Medicaid Services (CMS) launched a process that permits state access to Medicare Parts A, B, and D data in response to several state requests for claims information to improve how they manage care for dual eligible beneficiaries. Data that may be requested, subject to procedural limitations, are:

  • Medicare Parts A and B claims and Part D prescription drug event data;
  • Medicare Parts A, B, C, and D eligibility and enrollment data;
  • Assessments data, including Minimum Data Set (MDS), Outcome and Assessment Information Set (OASIS), Swing Bed, and Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI); and
  • Medicare Provider and Analysis Review (MedPAR) and Medicaid Enrollee Supplemental File (MESF) data.

CMS established a process to expand the permissible use of the same Medicare data provided to states for care coordination to include program integrity purposes. The data provide state Medicaid agencies with Medicare claims information for dual eligible beneficiaries to prevent duplicate payments by Medicare and Medicaid as well as other overpayments, such as Medicaid payment for home health services during Medicare-paid institutionalizations. Medicare data can assist state Medicaid agencies with safeguarding their respective Medicaid programs from fraud, waste, and abuse (FWA) while ensuring the prudent use of taxpayer dollars. Other example data uses for anti-FWA activities include, but are not limited to:

  • Skilled nursing facility (SNF) churning;
  • Provider billing patterns;
  • Detecting duplication of services;
  • Auditing providers for services rendered;
  • Conducting quality performance measures; and
  • Value-based payment (VBP) activities.

The Center for Program Integrity (CPI) enables states to access Medicare data for program integrity purposes while receiving technical assistance from the State Data Resource Center (SDRC) Support Team and CMS.