The Centers for Medicare & Medicaid Services in coordination with States are committed to combating Medicaid provider fraud, waste, and abuse, which diverts dollars that would otherwise be spent to safeguard the health and welfare of Medicaid beneficiaries.
In February 2006, the Deficit Reduction Act of 2005 signed into law and created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act. The MIP is the first comprehensive Federal strategy to prevent and reduce provider fraud, waste, and abuse in the Medicaid program.
Report Fraud, Waste, & Abuse!
Fraud is defined in the Medicaid rules as, “An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law.”
Waste encompasses the over-utilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act.
Abuse is related to poor fiscal, business or medical practices that increase costs, such as reimbursement for services that are not medically necessary, coding errors, and other mistakes. An honest mistake should lead to the return of funds to Medicaid.
Providers who improperly bill for services and beneficiaries who cause unnecessary costs, risk losing continued eligibility to participate in the Medicaid program and may face criminal and civil monetary penalties.
Some examples of fraud, waste, and abuse include:
- A Medicaid client sharing their card with other people who are not entitled to receive Medicaid services;
- Billing for services not rendered;
- Modifying medical records;
- Utilizing unlicensed staff;
- Billing duplicate claims;
- Upcoding, etcetera…
Let us know if you’ve witnessed instances of fraud, waste, and abuse! Report fraud, waste, and abuse of Medicaid services by clicking here.
Program Integrity Fundamentals
- Fraud, waste, and abuse are investigated through preliminary investigations and full-scale investigations. Outcomes determine whether recovery of State/Federal funds is warranted and/or if law enforcement agencies need to become involved.
- Program Integrity functions:
- Provider Education
- Perform Pre-payment Review (client eligible/provider eligible, etc.)
- Perform Post-payment Review of Claims for Validity
- Receive & Investigate Complaints
- Receive & Investigate Referrals
- Wyoming Medicaid Documentation Standards
- How Program Integrity detects areas to review:
- Data Mining
- Explanation of Medical Benefits
- Media Monitoring
- Site Visits
- Internal-State (Medical Reviews, Claims Payment Reviews)
- External Federal Audits (PERM; MIC: Medi-Medi)
- Provider Self-Audits
- State Provider Audits Conducted Through Record Requests
- Administrative Process:
- Overpayment Recovery
- Administrative Hearing Process
- Provider Enrollment Verification
|Medicaid Integrity Group (MIG)||CMS||Reviews provider activities, audits claims, identifies overpayments, educates providers, supports state PI teams and MFCUs||Activities completed by vendors known as Medicaid Integrity Contractors (MICs)|
|Payment Error Rate Measurement (PERM) Program||CMS||Conducts audits to measure error rates of improper payments
for Medicaid and Children’s Health Insurance Program (CHIP)
|17 states are audited each year using random sampling techniques to calculate payment error rates|
|Medicare-Medicaid (Medi-Medi) Data Match Program||CMS||Helps states analyze billing patterns across Medicare and Medicaid||Participation is optional|
|Office of the Inspector General (OIG)||HHS||Audits, investigates and assesses all HHS programs||Funds and oversees state MFCUs|
|Department of Justice (DOJ)||DOJ||Monitors and enforces federal laws and prosecutes criminals||Directs law enforcement agencies, including the Offices of the U.S. Attorneys, the Criminal Division and the Federal Bureau of Investigation (FBI)|
|Medicaid Integrity Institute (MII)||CMS/DOJ||Provides customized training, technical assistance and support to state Medicaid PI employees||National Medicaid PI training center for states located at DOJ’s National Advocacy Center in Columbia, S.C.|
|Health Care Fraud and Abuse Control (HCFAC) Program’s Health Care Fraud Prevention and Enforcement Action Team (HEAT)||DOJ/HHS||HCFAC coordinates federal, state and local law enforcement activities related to investigating and prosecuting criminal activity; HEAT investigates suspicious
Medicare and Medicaid providers
|Staff includes law enforcement agents, prosecutors, attorneys, auditors and evaluators|
|Government Accountability Office (GAO)||Congress||Audits federal agencies, evaluates programs and makes
recommendations for improvements
|Congressional agency investigates spending and fraud across
This information is made available and updated on a periodic basis to benefit the public and increase transparency.
This page was last updated on March 22, 2017. Thank-you very much for visiting!