Strengthening Program Integrity: NAMD’s Recommendations on CMS’ CRUSH Initiative

This snapshot provides a high-level summary of NAMD’s comments on CMS’ Request for Information (RFI) on Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH). The RFI seeks stakeholder input on opportunities to strengthen program integrity and reduce fraud, waste, and abuse (FWA) across Medicaid, Medicare, CHIP, and the Marketplace. NAMD’s comments highlight five key areas where CMS can work with states and territories to strengthen program integrity: federal–state coordination, high-risk service areas, data sharing, provider oversight, and analytic capacity. For a more detailed analysis, read NAMD’s full comments here.

Background: Why This Matters

CMS has elevated program integrity as a priority, with recent actions focused on preventing fraud, improving oversight, and reducing improper payments across federal health programs. The CRUSH RFI builds on these efforts by seeking input on how to strengthen tools, data, and coordination to better detect and prevent fraud, waste, and abuse.

Medicaid agencies play a central role in these efforts. As primary administrators of the program, states and territories are responsible for safeguarding public resources while ensuring eligible individuals receive needed care. Agencies utilize a wide range of program integrity tools to do this, including provider screening, pre- and post-payment audits, and coordination with law enforcement partners.

At the same time, program integrity risks are evolving. Fraud schemes are increasingly sophisticated and often span programs and jurisdictions, making them more difficult for any single entity to detect and address independently. These dynamics highlight the need for stronger coordination, shared data, and aligned federal and state/territory strategies to effectively identify and address emerging risks.

NAMD’s Policy Perspective

States and territories emphasized the importance of clearly distinguishing between fraud, waste, and abuse, as each involves different drivers and requires different responses:

1. Fraud involves intentional misconduct, and Medicaid agencies work closely with law enforcement entities to investigate and address fraudulent activity.
2. Abuse refers to services that exceed medical necessity, whether intentional or unintentional, and is addressed through a range of administrative, civil, and in some cases criminal enforcement mechanisms under federal and state law.
3. Waste reflects inefficient use of resources, and, unlike fraud and abuse, is generally not tied to specific legal violations, but still contributes to improper spending.

Effective program integrity efforts must address all three in a coordinated way.

Medicaid agencies share the federal government’s strong commitment to safeguarding Medicaid funds and view program integrity as a core responsibility of administering the program. States and territories operate on the front lines of these efforts and have deep operational experience in detecting and addressing program integrity risks.

Given the increasing complexity of fraud schemes and their ability to span programs and jurisdictions, agencies emphasized that collaboration between Medicaid agencies and CMS is foundational to effectively addressing emerging challenges. Strengthening coordination across federal and state partners is key to improving oversight, closing system gaps, and ensuring consistent approaches to program integrity.

NAMD’s Key Recommendations

NAMD’s recommendations focus on five key areas where CMS can most effectively support state and territory efforts, including:

• Strengthening the federal and state partnership through training, technical assistance, and structured collaboration
• Providing targeted support for high-risk service areas that present elevated program integrity risks
• Improving data sharing and national visibility, including through enhanced use of T-MSIS
• Enhancing information sharing on providers and enforcement actions across programs
• Expanding access to tools, technology, and analytic capacity to support program integrity efforts

We briefly summarize our recommendations in these five domains in the sections below.

Strengthening the Federal–State Partnership

Medicaid agencies emphasized that CMS is uniquely positioned to strengthen program integrity by serving as a central coordinating partner across states, territories, and federal entities. Collaboration across levels of government is essential to strengthening oversight and addressing emerging risks.

States and territories identified several opportunities for CMS to strengthen coordination, expand access to training and technical assistance, and facilitate more structured collaboration across partners, including:

• Expanding access to the Medicaid Integrity Institute (MII), which provides valuable training on audit design, provider enrollment, data analytics, and law enforcement referrals, and broadening participation beyond program integrity staff to other relevant Medicaid agency personnel.
• Strengthening peer-to-peer learning opportunities by facilitating structured forums for states and territories to share best practices, discuss emerging risks, and learn from each other through webinars, toolkits, and regular convenings.
• Enhancing the role of the Fraud, Waste, and Abuse Technical Advisory Group (FWA-TAG) by increasing the consistency of meetings, improving structure, and supporting more active CMS leadership in agenda-setting and stakeholder engagement.
• Convening key program integrity partners, including Medicaid agencies, program integrity units, Medicaid Fraud Control Units (MFCUs), and national partner organizations such as NAMD, the National Association for Medicaid Program Integrity (NAMPI), and the National Association of Medicaid Fraud Control Units (NAMFCU).

NAMD emphasized that CMS can add the most value by acting as connective infrastructure across a fragmented program integrity landscape, rather than duplicating state-level activities.

Targeted Support for High-Risk Service Areas

Medicaid agencies emphasized that certain service areas and provider types present elevated risks for fraud, waste, and abuse and should be a priority focus for federal support. These risks are inherent in a program as complex as Medicaid and are particularly pronounced in services with unique delivery systems and billing structures.

For example, home and community-based services (HCBS), applied behavioral analysis (ABA), and other services delivered in community-based settings or by non-traditional or unlicensed providers can present program integrity challenges due to decentralized delivery models and variation in oversight practices.

States and territories already conduct enhanced monitoring and oversight in high-risk service areas. However, agencies noted that these efforts could be strengthened through additional federal support and coordination, such as:

• CMS could support states by developing national risk indicators for high-risk services and providers, allowing agencies to better target oversight efforts. Sharing information on common fraud schemes and emerging trends would also improve early detection and prevention.
• CMS could provide more targeted guidance on monitoring strategies, including more frequent provider reverification and clearer documentation expectations.

At the same time, it is important to maintain flexibility. States operate within diverse delivery systems and serve different populations, and federal support should enhance, not constrain, states’ ability to tailor program integrity strategies to their specific contexts.

Improving Data Sharing and Visibility Across Programs

Medicaid agencies consistently identified data sharing and visibility as one of the most significant opportunities to strengthen program integrity efforts. While states have strong visibility into their own program data, they have limited insight into provider activity, fraud trends, and enforcement actions occurring across other states or federal programs.

CMS is uniquely positioned to address this gap. Through national datasets, particularly the Transformed Medicaid Statistical Information System (T-MSIS), CMS has a line of sight across all states and territories that no individual state can replicate. This creates a valuable opportunity to identify cross-state billing patterns, detect emerging fraud schemes, and flag providers operating across multiple jurisdictions.

Agencies emphasized the need to shift from passive data collection to actionable intelligence, such as receiving targeted alerts, risk indicators, and analyses that can be integrated into program integrity workflows. When adverse actions are taken in one state, CMS could notify other states where that provider is active to allow for more coordinated and timely responses.

In addition to broader data visibility, states and territories highlighted ongoing challenges with delays and gaps in sharing information on provider sanctions, payment suspensions, enrollment denials, and other enforcement actions. Because providers and billing entities often operate across multiple jurisdictions, these gaps create opportunities for bad actors to continue operating across states or programs.

CMS could support program integrity efforts by establishing centralized, real-time or near real-time systems that allow states to access information on sanctioned, revoked, or otherwise high-risk providers and entities. Expanding beyond existing exclusion lists to include a broader range of administrative actions would further strengthen oversight.

CMS could also facilitate routine, rapid communication of fraud findings and enforcement actions across federal and state programs, including Medicare, Medicaid, the Department of Veterans Affairs, and other public payers. Improved visibility into national trends, provider activity, and enforcement actions would help states anticipate emerging risks and respond more effectively to program integrity challenges. To be effective, these efforts should prioritize usability and ensure that data is structured, timely, and operationally relevant.

Expanding Tools, Technology, and Analytic Capacity

Medicaid agencies increasingly rely on data analytics, predictive modeling, and emerging technologies to identify potential fraud and prioritize investigations. However, the effectiveness of these efforts depends on access to high-quality data, modern tools, and interoperable systems.

States reported challenges related to fragmented tools, duplicative investments, and limited access to key federal and cross-program datasets. CMS is well positioned to support states by facilitating access to shared analytic platforms and secure data-sharing tools, reducing the need for states to build capabilities independently.

Expanding access to additional data sources, including Medicare data for dually eligible individuals and other federal datasets, would allow states to develop a more complete picture of provider activity and identify suspicious patterns effectively. Improving interoperability and streamlining access to these data sources would further strengthen program integrity efforts. CMS could also support the use of advanced analytics and artificial intelligence tools, while providing guidance on appropriate safeguards and implementation. Additional federal funding or enhanced matching opportunities for program integrity technology investments would further support modernization efforts.

Moving Forward

Medicaid agencies remain strongly committed to safeguarding program integrity and ensuring that Medicaid funds are used appropriately and effectively. States and territories have built robust systems to detect and prevent fraud, waste, and abuse and continue to adapt these efforts in response to evolving risks. Strengthening the array of existing program integrity strategies and tools will require enhanced coordination, improved data sharing, and continued collaboration between federal and state partners. NAMD looks forward to continuing to partner with CMS to advance program integrity strategies across diverse state and territory environments.