Federal scrutiny of Medicare and Medicaid programs is entering a new phase. Across the country, the Centers for Medicare & Medicaid Services (CMS) and state agencies are increasing their focus on fraud, waste and abuse (FWA), placing greater pressure on health plans to strengthen program integrity efforts and prevent improper payments before they occur.
Recent actions in several states illustrate the scale of this shift. Florida was recently designated a federal “hot spot,” prompting CMS to require enhanced prepay fraud controls, targeted monitoring of high-risk service areas, provider revalidation, and expanded program integrity reporting. California faced a historic $1.3 billion Medicaid funding deferral tied to prior expenditures, while Minnesota and Hawaii have also encountered significant federal actions related to program integrity and fraud prevention.
For health plans, the message is clear: compliance and payment accuracy are increasingly moving upstream.
This shift should not be interpreted as a widespread move towards one specific type of prepayment solution. Rather, oversight efforts are primarily directed at ensuring compliance and monitoring of service areas that show higher levels of growth, utilization, or potential fraud risk. Health plans are being encouraged to strengthen targeted prepay controls and implement more sophisticated methods for identifying questionable claims before payment is made, creating new opportunities to improve both compliance and payment accuracy.
As a result, many organizations are reevaluating their payment integrity strategies and seeking partners who can support compliance-driven audits while also delivering measurable savings. The ability to combine regulatory expertise, clinical insight, and advanced analytics is becoming increasingly important as plans adapt to a more rigorous oversight environment.
At CERIS, we believe this evolution represents more than a compliance requirement, it is an opportunity for health plans to modernize their payment integrity programs. While cost containment remains a critical objective, the future of payment integrity will increasingly be defined by proactive prevention, defensible outcomes, and the ability to identify risk before improper payments occur.