Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care

摘要

As health care costs continue to rise to unprecedented heights, States areseeking new approaches in providing health care services for their citizens. More and more States are moving their Medicaid program away from the traditional fee-for-service (FFS) environment to a managed care system or a capitated environment. With this shift in health care comes new challenges in containing costs and new opportunities for fraud and/or abuse to occur. The original thinking of many within the industry was that fraud did not exist in managed care. However, experience has proven that fraud does, in fact, exist in many ways within a managed care environment. States are required by Federal mandate to have an effective fraud and abuse detection and prevention program; however, few formal managed care fraud and abuse programs have been initiated by States. The purpose of these guidelines is to assist the Health Care Financing Administration, State Medicaid Agencies, Medicaid Fraud Control Units, and managed care organizations in preventing, identifying, investigating, reporting, and prosecuting fraud and abuse in a Medicaid managed care environment, and to better equip States with new measures and initiatives to protect against fraud and abuse in Medicaid managed care programs.