United States

The state of oversight and program integrity in managed care

Aug 03, 2017
From the Government Institute

The effective oversight of a state's managed care partners is imperative for a resilient, cost-effective, and high-integrity Medicaid program. Under CMS's 2016 managed care mega-rule, federal regulations concerning Medicaid managed care are undergoing a process of significant reform to increase access to care, improve the quality of care delivered, and contain costs. While these reforms are designed to streamline and strengthen managed care, it has brought to light broader questions of the integrity of managed care programs and their effectiveness in operation, particularly when it comes to oversight and fraud, waste, and abuse monitoring.

This issue brief discusses three key components of managed care oversight and program integrity, including:

  1. Managed care organization monitoring and regulatory framework
  2. Fraud, waste, and abuse and improper payments in a managed care context
  3. The role of intelligent automation in managed care oversight and program integrity


Anthony  Monaco

Anthony Monaco

National Lead Partner for State and Local Risk Consulting
+1 212-872-6448 LinkedIn