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Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care

This document outlines essential guidelines for addressing fraud and abuse in Medicaid Managed Care programs, emphasizing compliance, oversight, and best practices for organizations involved in Medicaid services. It provides detailed instructions for constructing effective compliance programs suitable for Medicaid Managed Care Organizations and Prepaid Health Plans. Additionally, it references important reports from Florida and Ohio that assess program performance and highlight areas of improvement. The information aims to foster better management and accountability in Medicaid services.

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Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care

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    1. August 2007 1 Welcome and Introductions Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care (October 2000) http://www.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp#TopOfPage NOTE: Scroll to bottom of page and select Managed Care - click on fraudgd.pdf. Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans (May 2002) http://www.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp#TopOfPage NOTE: Scroll to bottom of page and select Managed Care click on mccomplan.pdf. The Florida Senate Interim Project Report 2006-133 (November 2005) http://www.flsenate.gov/Publications/2006/Senate/reports/Workprogram/pdf/workprogram.pdf (Page 97) Ohio Performance Audit (December 2006) http://www.auditor.state.oh.us/AuditSearch/Reports/2006Ohio_MedicaidProgram_12_19.pdf NOTE: This file will take approximately 11 minutes to download.

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