Healthcare fraud is a significant problem faced by all state, federal, and private health plans. The Department for Medicaid Services (DMS) works with the Office of the Inspector General (OIG) and the Office of the Attorney General (OAG) to combat fraud and abuse.
The Division of Program Integrity guards the Medicaid program against fraud, waste, and abuse by providers and members and assures compliance with federal and state Medicaid regulations.
Audits and Compliance Branch
The Audits and Compliance Branch partners with federal and state law enforcement agencies and Managed Care Organizations (MCO) to identify Medicaid fraud, waste, and abuse.
Audits are conducted based on patterns or trends identified through in-house data mining and algorithms, high service utilizers, required federal audits, Healthcare Fraud Prevention Partnership (HFPP) tips, OIG hotline complaints, member and provider complaints, and other agency referrals.
Recovery Branch
The Recovery Branch in the Division of Program Integrity is responsible for several key tasks related to Medicaid, including helping the department identify and respond to Medicaid fraud, waste, and abuse. The branch serves as the liaison for audits conducted by the Unified Program Integrity Contractor (UPIC) and works closely with the Audits and Compliance Branch in establishing the necessary accounts resulting from conducted audits.
Fraud referrals for providers and/or members can be identified from Explanation of Medical Benefits (EOMBs) documents, newspaper and television reports, federal alerts, etc. Once an overpayment is identified, the Recovery Branch initiates a review and begins the process of collecting outstanding accounts.
Before any change to a provider's participation in the Medicaid program, the Recovery Branch reviews the provider's application, maintenance, and revalidation for provider enrollment. In addition to outstanding accounts, staff also oversee and monitor Denial of Payment for New Admissions for Nursing Facilities received from the Centers for Medicare and Medicaid Services (CMS). The Recovery Branch also reviews and establishes accounts for providers and/or members who are the subject of a fraud investigation.
The branch receives and researches bankruptcy notices to protect the Department's interests; provides Date of Death account monitoring for providers and members if claims have been paid after the date of death; and communicates regularly with many areas, including sister agencies, contractors, and federal partners. Additionally, the branch is tasked with researching the receipt of bills by members when they are eligible for Medicaid and reviewing Medicaid members who engage in fraudulent behavior.