CMS FY2023 Focused Program Integrity Review — Minnesota (Final Report)

Source: Centers for Medicare & Medicaid Services · Document date: 2023-12-01 · Type: Audit Report

CMS Focused Program Integrity Review Contractor (FPIRC) final report for Minnesota FY2023. Found that MCO fraud referrals to DHS were 'low relative to program size' with only 3 of 9 MCOs submitting more than 10 referrals per year. Documented that MCO SIU staffing ratios (avg 1:21,400) fell below the CMS Toolkit benchmark of 1:10,000. Included five observations on site visits, referral criteria, data sharing, and encounter data quality.

Significance: The authoritative federal source for the MCO fraud referral gap finding. Directly cited in the key takeaway that CMS found MCO-to-DHS referrals 'low relative to program size.'

Tags: CMS, FPIRC, program-integrity, managed-care, Minnesota, referrals