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PROGRAM INTEGRITY

The Deficit Reduction Act of 2005 created the Medicaid Integrity Program (MIP) in section 1936 of the Social Security Act (the Act), and dramatically increased the Federal government's role and responsibility in combating medicaid fraud, waste and abuse.  Section 1936 of the Act requires the Centers for Medicare & Medicaid Services (CMS) to contract with eligible entities to review and audit Medicaid claims, to identify overpayments, and provide education on program integrity issues.  Additionally, the Act requires CMS to provide effective support and assistance to States to combat Medicaid provider fraud and abuse.  To see further details of the Medicaid Integrity Program click on the following link:

Medicaid Integrity Program A to Z

Provider Audits FAQs

 

Medicaid Program Integrity:

  • Strives to ensure compliance with state and federal statutes and regulations to assure that services are provided in the most appropriate and cost-effective manner for all services.
  • Monitors estate recovery and third party liability rules and regulations.
  • Strives to track down fraudulent and/or abusive behaviors draining Medicaid of valuable monies that could otherwise be used for services.

If you suspect any form of abuse of the Medicaid healthcare system, you may file a report in any one of the following ways:

Examples of Abuse:

  • Repeated submission of claims with missing or incorrect information.
  • Repeated submission of claims with procedure codes that overstate the service provided.
  • Repeated submission of claims that deny.
  • Failure to maintain appropriate medical records.
  • Failure to use generally accepted accounting principles.
  • Excessive or inappropriate patterns of referrals.
  • Repeated submission of claims for services that were not medically necessary.
  • Repeated submission of claims for services beyond what was agreed to by the patient.
  • Over-prescribing or mis-prescribing pharmaceutical products or services.
  • Repeated submission of claims without complying with third party liability requirements.
  • Allowing use by another client of a client's Medicaid identification card.
  • Obtaining services which are not medically necessary.
  • Obtaining duplicate services from more than one provider.
  • Misuse.

Examples of Fraud:

  • An intentional deception or misrepresentation made by an individual with the knowledge that the deception or misrepresentation may result in excess payments.
  • Includes any actions or inactions that constitute fraud under federal or state law.

To review the entire rule for Medicaid Program Integrity go to: The Secretary of State Rules Data Base