The Case for Program Integrity in Medicaid Managed Care

Part One: The Current Landscape and Industry Issues

Myers and Stauffer is pleased to present a multi-part blog series, brought to you by our Benefit/Program Integrity Team. In this series, we will take an intensive look at the various components of managed care and program integrity, how they fit together, the salient aspects of each, and why it all matters. In this first post, we provide insight, driven by industry developments and current events, into why these issues are so important – for those charged with oversight of managed care programs and for their beneficiaries and the people they serve.

Cases of health care fraud, waste, and abuse (FWA) are making headlines…and with good reason. In June 2025, the Department of Justice reported:

“The Justice Department today announced the results of its 2025 National Health Care Fraud Takedown, which resulted in criminal charges against 324 defendants, including 96 doctors, nurse practitioners, pharmacists, and other licensed medical professionals, in 50 federal districts and 12 State Attorneys General’s [sic] Offices across the United States, for their alleged participation in various health care fraud schemes involving over $14.6 billion in intended loss. The Takedown involved federal and state law enforcement agencies across the country and represents an unprecedented effort to combat health care fraud schemes that exploit patients and taxpayers.

“Demonstrating the significant return on investment that results from health care fraud enforcement efforts, the government seized over $245 million in cash, luxury vehicles, cryptocurrency, and other assets as part of the coordinated enforcement efforts. As part of the whole-of-government approach to combating health care fraud announced today, the Centers for Medicare and Medicaid Services (CMS) also announced that it successfully prevented over $4 billion from being paid in response to false and fraudulent claims and that it suspended or revoked the billing privileges of 205 providers in the months leading up to the Takedown. Civil charges against 20 defendants for $14.2 million in alleged fraud, as well as civil settlements with 106 defendants totaling $34.3 million, were also announced as part of the Takedown.”

The scope and significance of these cases, and their far-reaching effects around the country, demand attention. Similarly, other reports, from a range of outlets, have exposed high-profile, high-dollar accounts of FWA because of managed care organizations (MCOs) failing to maintain proper PI oversight of their providers, including delegates such as pharmacy benefit managers (PBMs). In fact, look for a Case Study (related to our actual engagements) in an upcoming installment entitled Part Four – Managed Care and Program Integrity Oversight of Subcontractors that details the importance of oversight of delegated entities.

In the interim, we invite you to join us for each installment along the way to learn about how FWA show up in managed care (and its different dimensions), what the consequences can be, and how those charged with PI oversight can address these issues and protect the accuracy and efficiency of Medicaid payments, processes, and systems, all for the ultimate goal of serving the nation’s most fragile and needy individuals.

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Established in 1977, Myers and Stauffer is a nationally based consulting and certified public accounting firm. For nearly 50 years, we have worked exclusively with local, state, and federal government health and human-services agencies to help them accomplish their most critical goals for the nation’s most fragile people. We are here to answer any questions and help with any health and human services needs your agency may be encountering.