Evaluating Effectiveness of Program Integrity Efforts

The Centers for Medicare & Medicaid Services (CMS) undertakes a wide range of program integrity activities to detect, prevent, and address fraud in Medicare and Medicaid. To ensure resources are directed toward the most effective efforts, CMS needs to understand which interventions are achieving their intended outcomes and where opportunities for improvement exist. Measuring effectiveness, however, can be challenging. Traditional metrics often focus on dollars recovered or avoided, which may not fully reflect the value of activities that identify problematic behavior early or prevent improper payments before they occur. CMS therefore faces the challenge of developing evaluation approaches that align performance measurement with its broader program integrity objectives.

Emendata works with CMS to develop frameworks to evaluate program integrity efforts based on the outcomes they are designed to achieve. Our team helps define and test measures that align with program goals, such as identifying fraudulent activity earlier. Translating these objectives into measurable performance indicators can provide a more meaningful view of program effectiveness.

These insights help identify opportunities for improvement and support decisions about where future program integrity resources can have the greatest impact. This approach gives CMS a more objective and comprehensive way to evaluate fraud-fighting efforts and prioritize strategies that deliver meaningful program integrity outcomes.