Medicaid program integrity

News and updates

Core objectives

The Health Care Authority's program integrity team:

• Promotes accountability in the administration of public funds.
• Encourages provider and managed care entity compliance, including self-disclosure of improper payments.
• Holds managed care entities accountable for maintaining effective systems to prevent, detect, and report improper payments.
• Identifies and addresses vulnerabilities that impact Apple Health programs.
• Ensures providers meet enrollment and participation requirements.
• Ensures clients meet eligibility requirements.
• Enforces payer-of-last-resort requirements, including coordination with Indian Health Service (IHS).

Program integrity activities

HCA conducts a range of activities to prevent, detect, and respond to fraud, waste, and abuse (FWA), including:

• Data analytics and risk-based monitoring.
• Provider utilization profiling.
• Audits and clinical reviews.
• Investigation of allegations of fraud, waste, or abuse.
• Implementation of payment suspensions when appropriate.
• Provider termination and exclusion actions.
• Referral and reporting to state and federal partners.
• Managed care oversight and enforcement, including sanctions.
• Provider education and outreach.
• Payment system controls and edits.
• Development and maintenance of policies and rules.
• Compliance with federal program integrity initiatives.

Outcomes

These activities support:

• Identification and recovery of improper payments.
• Prevention of future program vulnerabilities.
• Strengthened oversight of managed care and fee-for-service delivery systems.
• Protection of program integrity and public trust.