What is Program Integrity?

 

With the ever-increasing demand for public health assistance combined with severe budget constraints, public programs must be administered properly in order to protect and maintain funding for critical healthcare services. Whenever overpayment, fraud, or abuse of program services occurs, access to valuable healthcare services for vulnerable populations is reduced. The goal of Pharmacy Services is to provide a high measure of pharmacy program accountability by:

  • Conducting post-payment reviews of pharmacy claims through desk and on-site audits--reviewing claims of service to providers and recipients to identify, prevent, reduce, and recover payment errors
  • Conduct post-payment reviews as a means of identifying and investigating potential fraudulent behavior on the part of recipients and providers, such as drug-seeking behavior, billing irregularities, and the under/overuse of healthcare services
  • Review claims paid by our fiscal agent to ensure that payments are accurate and that system edits and audits are working properly. If deficiencies are detected, corrective actions are identified, executed, and monitored to ensure that remediation efforts were successful.
  • Investigate complaints from providers and recipients (i.e., regarding reimbursements, co-payments, availability of services, etc.) and introduce corrective action through education, training, referrals to licensing boards and the Attorney General if necessary

If you suspect fraudulent activity involving Medicaid providers or recipients, please click on the following to download a referral form or for more information about reporting potential fraud and abuse:

The Pharmacy Lock-In Program Referral Form

The Division of Healthcare Financing Program Integrity Information