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Medicaid and CHIP Payment and Access Commission

Program Integrity

Fraud, waste, and abuse (FWA) in Medicaid diverts program funds from their intended purpose, affecting both spending and beneficiary care. It encompasses acts of intentional deception (fraud), exploitation of care or payment systems (abuse), and unnecessary use of health care resources (waste). FWA occurs in both privately funded health care and government-funded health care programs such as Medicare and Medicaid.

Program integrity refers to the activities undertaken to prevent FWA and ensure that federal and state taxpayer dollars are spent appropriately on delivering quality, necessary care. Although program integrity was not an original feature of the Medicaid program, legislation has added safeguards to protect it from FWA.

MACPAC resources on program integrity in Medicaid:

Featured Publications

Provider Enrollment and Credentialing in Medicaid

June 15, 2026

Chapter 7 looks at Medicaid provider enrollment and managed care credentialing, which is designed to ensure that Medicaid enrollees receive care from qualified providers. In addition, these processes are intended to prevent the enrollment of providers who have criminal records related to federal health programs or who have engaged in fraud, waste, or abuse. The […]

Medicaid Program Integrity

April 16, 2026

In this issue brief, MACPAC analyzed data from government sources to identify known instances of fraud, waste, and abuse, as well as issues impacting the integrity of the Medicaid program. The brief defines fraud, waste, and abuse and discusses measures of fraud, waste, and abuse in Medicaid. It provides an overview of program integrity responsibilities […]

Comment Letter: Medicaid Program Integrity

March 30, 2026

In response to a Centers for Medicare & Medicaid Services (CMS) request for information on combatting fraud, waste, and abuse in federal health care programs, MACPAC outlined four areas where we have evidence-based findings and recommendations: identifying and eliminating ineffective or redundant program integrity (PI) activities and requirements, promoting high-value PI activities, barriers to PI […]