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Medicaid Information Technology: CMS Supports Use of Program Integrity Systems But Should Require States to Determine Effectiveness

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Medicaid is a joint federal-state program that provides health care coverage to certain low-income individuals. The program is overseen by CMS, while the states that administer Medicaid are tasked with taking actions to ensure its integrity. Such actions include implementing IT systems that provide program integrity analysts with capabilities to assess claims, provider, be Medicaid is a joint federal-state program that provides health care coverage to certain low-income individuals. The program is overseen by CMS, while the states that administer Medicaid are tasked with taking actions to ensure its integrity. Such actions include implementing IT systems that provide program integrity analysts with capabilities to assess claims, provider, beneficiary, and other data relevant to Medicaid; and supporting efforts to prevent and detect improper payments to providers. GAO was asked to review states' implementation of IT systems that support Medicaid. GAO determined (1) the types and implementation status of the systems used by states to support program integrity initiatives; (2) the extent to which CMS is making available data, technical resources, and funds to support Medicaid programs' efforts to implement systems, and the effectiveness of the states' systems; and (3) key challenges that Medicaid programs have faced in using IT to enhance program integrity initiatives, and CMS's actions to support efforts to overcome them. To do this, GAO analyzed information from 10 selected states covering a range of expenditures on such systems, reviewed program management documentation, and interviewed CMS officials.


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Medicaid is a joint federal-state program that provides health care coverage to certain low-income individuals. The program is overseen by CMS, while the states that administer Medicaid are tasked with taking actions to ensure its integrity. Such actions include implementing IT systems that provide program integrity analysts with capabilities to assess claims, provider, be Medicaid is a joint federal-state program that provides health care coverage to certain low-income individuals. The program is overseen by CMS, while the states that administer Medicaid are tasked with taking actions to ensure its integrity. Such actions include implementing IT systems that provide program integrity analysts with capabilities to assess claims, provider, beneficiary, and other data relevant to Medicaid; and supporting efforts to prevent and detect improper payments to providers. GAO was asked to review states' implementation of IT systems that support Medicaid. GAO determined (1) the types and implementation status of the systems used by states to support program integrity initiatives; (2) the extent to which CMS is making available data, technical resources, and funds to support Medicaid programs' efforts to implement systems, and the effectiveness of the states' systems; and (3) key challenges that Medicaid programs have faced in using IT to enhance program integrity initiatives, and CMS's actions to support efforts to overcome them. To do this, GAO analyzed information from 10 selected states covering a range of expenditures on such systems, reviewed program management documentation, and interviewed CMS officials.

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