Skip to main content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it's official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you're on a federal government site.


The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

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 2024