Performance Improvement 2008. Do States Meet Federal Fraud and Abuse Prevention Requirements for State Children's Health Insurance Programs?


The study assessed the extent to which six States that had a State Children's Health Insurance Program (SCHIP): established methods and procedures that met Federal fraud and abuse prevention, detection, and investigation requirements; assessed these States' oversight of SCHIP contractors; and assessed oversight by CMS of States regarding these functions. Federal and State governments jointly fund SCHIPs to provide health care assistance to low-income children who do not qualify for Medicaid. States must establish safeguards against fraud and abuse. Little is known about the arrangements they have made to do so.

The States met requirements for prevention and detection of fraud and abuse by assigning responsibility to SCHIP contractors that had established such procedures. One of the States had not met Federal requirements for investigating suspected SCHIP fraud and abuse cases and referring cases to law enforcement. Although oversight mechanisms in the States addressed Federal requirements, they did not always enable States to know how well health plans were performing safeguard activities. CMS relied primarily on States for oversight of SCHIP fraud and abuse safeguards, although it has completed some onsite reviews of States.

Report Title: Fraud and Abuse Safeguards in Separate State Children's Health Insurance Programs,
Agency Sponsor:
OS-OIG, Office of Inspector General
Federal Contact:
Claire Barnard, 202-205-9523
Performer: Office of Inspector General

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"PerformanceImprovement2008.pdf" (pdf, 1.29Mb)

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