or falsification. The final rule provides for
other intermediate sanctions for specified
· suspension of all new enrollment
(including default enrollment),
· suspension of payment for beneficiaries enrolled after the effective date of
· appointment of temporary management,
· termination of the contract with the state.
States also retain the authority to impose
sanctions on an MMCE under state laws and
regulations for the same as well as additional
areas of non-compliance. 11
An inaccurate or incomplete data submission may initially subject an MMCE to a
corrective action plan under state laws, regulations, and/or the state’s contract with the
MMCE. The failure to fully implement the
corrective action plan, repetitive errors and
omissions in data submissions, or more egregious omissions and errors in a single data
submission may result in the imposition of
other sanctions under state laws, regulations,
and/or the state’s contract with the MMCE,
including significant monetary penalties
depending on the state.
By establishing and implementing defined
pre-submission reasonable-diligence review
protocols for data submissions, MMCEs add
an extra layer of compliance review and further the detection and prevention of FWA.
Data, information, and documents that might
not otherwise be closely reviewed for FWA
indicators (e.g., encounter data) would be subject to a testing and validation process with
the potential to uncover FWA.
Promoting and ensuring Medicaid program
integrity is a primary goal of the revised
Medicaid managed care program rules.
MMCE certifications play an integral role in
furthering Medicaid program integrity when
supported by well-conceived pre-submission
review and testing protocols. Pre-submission
data review ensures and supports that data
submissions are accurate, complete, and
truthful and that Medicaid program mandates and requirements are being fulfilled.
Pre-submission review also facilitates compliance with Medicaid program requirements
and provides an additional compliance program check on fraud, waste, and abuse.
1. 81 F.R. 27498: Medicaid and Children's Health Insurance Programs
(CHIP), Medicaid Managed Care, CHIP Delivered in Managed
Care, and Revisions Related to Third Party Liability, (May 6, 2016
Final Rule), codified at 42CFR PARTS 431, 433, 438 et. al. Available at
2. 42 CFR §438.2 (Definitions)
3. Jennifer Gerstoff and Sabrina Gibson: “Medicaid Encounter Data:
The Next National Data Set” The Public Interest; September 2016.
Available at bit.ly/2iH7IiA
4. 42 CFR §§438.5, 242, 802, 806, 808, and 818; 81 F.R. at 27738-27739
5. Vivian Byrd, Jessica Nysenbaum, and Debra Lipson: Medicaid
Managed Care Encounter Data: A Toolkit for Data Collection,
Validation, and Reporting. Centers for Medicare and Medicaid
Services, November 2013. Available at bit.ly/2jMIqDh
6. 42 CFR§§ 438.230(b)(1), 438.242(b)( 3)(i); 81 F.R. 27598, 27739
7. 42 CFR § 438.608(a)(1) and (a)( 5)
8. National Committee for Quality Assurance (NCQA): HEDIS® and
Performance Measurement. Available at bit.ly/2zdnyI8
9. 64 F.R. 61893, 61899 (OIG’s Compliance Program for Medicare
+ Choice Organizations Offering Coordinated Care Plans)
November 15, 1999. Available at bit.ly/2jgAJ4m
10. 31 U.S.C.§ § 3729-3733 (False Claims Act). Available at
11. 42 CFR §§438.700,702 and 704, 706 and 708