Form CMS-10244 Medicaid State Program Integrity Assessment (SPIA)

State Program Integrity Assessment (SPIA)
Data Collection Instrument
Contact Information
1

State:

2

Name:

3

Title

4

Phone number:

5

E-mail:

Program Characteristics
6

Medicaid Enrollment:

Fee-for-service recipients:
Managed care enrollees
a) Comprehensive managed care:
b) Primary care case management:
c) Other:
Please describe:
Total:

7

Organizational structure for
Medicaid Integrity activities
within the State:

Distinct Program Integrity Model
Inspector General (IG) Model
Hybrid Model

8

Activities that the State includes
under the scope of Medicaid
Integrity:
(check all that apply)

Audits
Investigations
SURS/Data Mining
Provider Enrollment
Provider Education/Communications
Managed care oversight
Other, please specify:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 1 of 11

9

Medicaid Integrity activities that
the State contracts out:
(check all that apply)

Audits
Investigations
SURS/Data Mining
Provider Enrollment
Provider Education/Communications
Managed care oversight
Other, please specify:

10

Estimate of expenditures for
Medicaid Integrity activities ($)
a) Audits:
b) Investigations:
c) SURS/Data Mining:
d) Provider Enrollment:
e) Provider
Education/Communications:
f)

Managed care oversight:

g) Other:
h) Total:

Planning
Staffing
11

Total number of FTEs (filled and
vacant) for all functions
considered to be Medicaid
Integrity:

Audits:
Filled:

Vacant:

Investigation:
Filled:

Vacant:

SURS/Data Mining:
Filled:

Vacant:

Provider Enrollment
Filled:

Vacant:

Provider Education/Communications:
Filled:

Vacant:

Other:
Filled:

Vacant:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 2 of 11

IT Resources
12

Inventory of IT resources used to
conduct Medicaid Integrity
activities:
(check all that apply)

SURS I
SURS II
Advanced SURS
RAMS II
PC-based SURS
CS-based SURS
Fraud and Abuse Detection System
Decision Support System
Ad-hoc reporting
Managed care encounter data system
Other, please specify:

Strategic Planning
13
Does the State have a
documented strategic plan to
address Medicaid Integrity:

For its FFS program(s)?
Yes
No
Not applicable
Briefly describe:
For its managed care program(s)?
Yes
No
Not applicable
Briefly describe:

14

(If yes to Q13)
How frequently are updates
made to the strategic plan?

For FFS program(s)?
Quarterly
Yearly
Bi-annually
Other, please specify:
Not applicable
For managed care program(s)?
Quarterly
Yearly
Bi-annually
Other, please specify:
Not applicable

Prevention
Provider Enrollment
15
Total number of participating
Medicaid providers:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 3 of 11

16

Number of providers applied
for enrollment in Medicaid
during FFY:

17

Number of providers denied
enrollment in Medicaid during
FFY:

18

Pre-enrollment screening
conducted on individuals/entities
applying for Medicaid provider
numbers:
(check all that apply)

In-state licensing board
Out-of licensing board
HHS OIG’s List of Excluded Individuals and Entities (LEIE)
GSA’s Excluded Parties List System
National Practitioners Data Bank
Health Care Integrity Protection Data Bank
Choice Point or Lexis-Nexis reviews
On-site visits
Criminal background investigations
Credentialing
Payroll Tax Records
Check if provider has another provider number under
which the provider made inappropriate payments
Other (please specify):

19

Does the State maintain its own
list of providers who have been
involuntarily dis-enrolled?

Yes
No

(If yes to Q19)
a) How is the list maintained?

b) Is the list available to the
public?

Paper
Web
Other, please specify:
Not applicable
Yes
No
Not applicable

(If yes to Q19b)
Please provide web address for
the list:
20

Does the State have written
policies giving direction to
providers and managed care
organizations on the types and
frequency of screenings they
should conduct on sub-entities
(e.g., owners, managing
employees)?

Yes
(If yes, provide applicable policy/contractual language):
No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 4 of 11

21

Does the State include language
in its MCO contracts specifying
Medicaid Integrity
requirements?

Third Party Liability (TPL) Program
22
Does the State include TPL as
part of its Medicaid Integrity
activities?
23

Does the State include TPL
recoveries as part of its
Medicaid Integrity return-oninvestment?

Prior Authorization
24
Does the State include prior
authorization as part of its
Medicaid Integrity activities?
25

Does the State include prior
authorization cost avoidance as
part of its Medicaid Integrity
return-on-investment?

Provider Education
26
Mechanisms used to
communicate to and educate
providers about Medicaid
Integrity:
(Check all that apply)

Yes
(If yes, provide applicable contractual language):
No
Yes
No
Yes
No

Yes
No
Yes
No

Fraud, waste, and abuse policy statements
Anti-fraud public service announcements
Speeches made by State Medicaid Agency
administrators or staff to stakeholder organizations
about Medicaid fraud, waste, and abuse.
News releases from State Medicaid Agency about
managing Medicaid fraud, waste, and abuse
Publications related directly to concerns of Medicaid
fraud, waste, and abuse.
Website dedicated to Medicaid Integrity regulations,
policies, and procedures.
Other (please describe):

Detection
27

Does the State have written
policies regarding issues
including, but not limited to:

How the State should investigate fraud, waste, & abuse?
Yes
No
How to secure evidence in a legally admissible form?
Yes
No
How to disseminate lessons learned from the case?
Yes
No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 5 of 11

28

Data repository platform used
for data mining:

Mainframe
Internal/external relational database (e.g., Oracle)
Vendor proprietary database
Name:
Mainframe data downloads to a personal computer (PC)
Commercial/off-the-shelf PC product
Name:
Other (please describe):
Name:

29

Data mining techniques used to
detect Medicaid fraud, waste &
abuse or inappropriate
payments:

Algorithms
Sampling
Statistical analysis
Models
Artificial intelligence/fuzzy logic
Other (please describe):

30

Data mining analysis tools used
to detect Medicaid fraud, waste
& abuse or inappropriate
payments:

Mainframe queries
SAS
SQL query
Vendor toolset
Name:
Commercial/off-the-shelf PC product
Name:
Other, please describe:
Name:

31

Overpayments ($) identified as
a result of data mining activities:

32

Percent of cases opened from
overpayments identified as a
result of data mining activities:

33

Does the State typically
extrapolate overpayments?

Yes
No

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 6 of 11

34

35

Total number of provider audits
conducted:
(State staff vs. Contractor staff)

Overpayments ($) identified as
a result of provider audits:

Desk Audits
State staff:

Contractor staff:

Field Audits
State staff:

Contractor staff:

Provider self-audits
State staff:

Contractor staff:

Combination desk/field audits
State staff:

Contractor staff:

Cost report audits
State staff:

Contractor staff:

Total
State staff:

Contractor staff:

Desk Audits:
Field Audits:
Provider self-audits:
Combination desk/field audits:
Cost report audits:
Total:

36

Mechanisms available to the
public for reporting cases of
suspected Medicaid fraud,
waste, or abuse:

37

Total number of tips received:

38

Total number of tips that
resulted in a recovery or
referral:

Telephone hotline
Website
Email address
Mailing address
Other, please specify:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 7 of 11

Investigation and Recovery
Referrals to Law Enforcement
39

Does the State have written
standard operating procedures
(SOPs) for determining how and
when providers should be
referred to the MFCU (per 42
CFR 455.13)?

Yes
No
If yes, briefly describe:

40

Does the State have tracking
systems that track the progress
of Medicaid Integrity
investigations?

Yes
No

41

Does the State have a process
to track the number of referrals
sent to the MFCU?

Yes
No

42

Does the State have a process
to track the date that referrals
were sent to the MFCU?

Yes
No

43

Does the State collect feedback
from the MFCU to determine the
number of accepted referrals?

Yes
No

44

Number of referrals accepted
by the MFCU:

45

Number of referrals made to
the MFCU:

Provider Suspensions & Sanctions
46

Does the State impose provider
payment suspensions due to
inappropriate or fraudulent
activities?

Yes
No

(If yes to Q46)
a) Number of providers that the
State suspended payment:
b) Number of payment
suspensions:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

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47

Does the State impose provider
sanctions due to inappropriate
or fraudulent activities?

Yes
No

(If yes to Q47)
a) Number of providers referred
to the State licensing board:
b) Number of providers
involuntarily dis-enrolled:
c) Number of provider sanctions
referred to OIG:

Cost Avoidance
48
Does the State calculate the
dollars cost avoided from
terminating providers?

Yes
No

(If yes to Q48)
a) Describe methodology for
calculating cost avoidance,
including data sources used:
b) Cost avoidance dollars from
terminated providers:

49

Does the State calculate the
dollars cost avoided from
providers that withdrew due to
program integrity concerns:

Yes
No

(If yes to Q49)
a) Describe methodology for
calculating cost avoidance,
including data sources used:
b) Cost avoidance dollars from
terminated providers:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 9 of 11

50

Does the State calculate cost
avoidance dollars due to
changes in payment systems?

Yes
No

(If yes to Q50)
a) Describe methodology for
calculating cost avoidance,
including data sources used:
b) Cost avoidance dollars due
to changes in payment
systems:
c) Does the State factor cost
avoidance from payment
system changes into its
budget
51

Does the State measure cost
avoidance dollars due to policy
changes?

Yes
No

Yes
No

(If yes to Q51)
a) Describe methodology for
calculating cost avoidance,
including data sources used:
b) Cost avoidance dollars due
to changes in policies
c) Does the State factor cost
avoidance from policy
changes into its budget?
52

Recoveries
53
54

Yes
No

List other administrative actions
for which the State calculates
cost avoidance:
Total recoveries ($) from data
mining activities:
Total recoveries ($) from
provider audits:
a) Desk Audits:
b) Field Audits:
c) Provider self-audits:
d) Combination desk/field
audits:
e) Cost report audits:
f)

Total:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 10 of 11

55

Total dollars recovered from ALL
Medicaid Integrity activities
(e.g., settlements/judgments,
overpayments & other
collections, MFCU investigations,
other civil/criminal law
enforcement, tips):

56

Identify up to 3 areas that the
State would like CMS to provide
technical assistance and support:

Technical Assistance Needs Assessment
1)
2)
3)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1033. The time required to complete this information collection is estimated to average 25 hours per response, including the time
to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of
the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Page 11 of 11