Office of the Inspector General (OIG) of the United States Department of Health and Human Services (HHS)

States Have Missed Some Opportunities to Improve Medicaid Managed Care Organizations’ Provider Fraud Referrals (OEI-03-23-00340)

This evaluation examines how states use contract requirements and other practices to improve the volume and quality of provider fraud referrals submitted by Medicaid managed care organizations (MCOs).  OIG found that the contracts states have with MCOs generally required MCOs to refer potential health care provider fraud to the relevant state.  However, key differences among the contracts include: 1) states specified different timeframes for MCOs to make referrals; and 2) a few states' contracts did not explain the actions the state could take if MCOs did not comply with fraud referral requirements.  To help states improve MCOs’ provider fraud referrals, OIG made four recommendations to the Centers for Medicare and Medicaid Services (CMS).