PROGRAM INTEGRITY
Medicaid Program Integrity:
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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.
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Monitors estate recovery and third party liability rules and regulations.
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Strives to track down fraudulent and/or abusive behaviors draining Medicaid of valuable monies that could otherwise be used for services.
Abuse:
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Repeated submission of claims with missing or incorrect inforamtion.
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Repeated submission of claims with procedure codes that overstate the service provided.
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Repeated submission of claims that deny.
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Failure to maintain appropriate medical records.
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Failure to use generally accepted accounting principles.
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Excessive or inappropriate patterns of referrals.
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Repeated submission of claims for services that were not medically necessary.
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Repeated submission of claims for services beyond what was agreed to by the patient.
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Over-prescribing or mis-prescribing pharmaceutical products or services.
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Repeated submission of claims without complying with third party liability requirements.
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Allowing use by another client of a client's Medicaid identification card.
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Obtaining services which are not medically necessary.
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Obtaining duplicate services from more than one provider.
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Misuse.
Fraud:
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An intentional deception or misrepresentation made by an individual with the knowledge that the deception or misrepresentation may result in excess payments.
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Includes any actions or inactions that constitute fraud under federal or state law.
If you suspect any form of abuse of the EqualityCare healthcare system, please download and complete the Report of Suspected Abuse and/or Fraud of the EqualityCare Healthcare System form and return it to the Program Integrity Unit at, Office of Healthcare Financing, 6101 Yellowstone Road, Ste. 210, Cheyenne, WY 82002.
To review the entire rule for Medicaid Program Integrity go to: http://soswy.state.wy.us/RULES/3346.pdf.