WHAT IS THE MEDICAID

INTEGRITY PROGRAM ?
October 2009

10/16/2009 1
 Who Are We?

„ The Medicaid Integrity Program (MIP) audits

and investigates Medicaid providers and
Medicaid beneficiaries suspected of misusing
Michigan’s Medicaid program. MIP works
to ensure that Medicaid money spent is used
for the best care of the beneficiaries.

10/16/2009 2
 Fraud, Waste, and Abuse
„ Fraud – 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. 42CFR§455.2
„ Abuse – Provider practices that are inconsistent with sound fiscal, business,
or medical practices, and result in an unnecessary cost to the Medicaid
program, or in reimbursement for services that are not medically necessary
or that fail to meet professionally recognized standards for health care. It
also includes beneficiary practices that result in unnecessary cost to the
Medicaid program. 42CFR§455.2
„ Waste – Involves the taxpayers not receiving reasonable value for money in
connection with any government funded activities due to an inappropriate
act or omission by players with control over or access to government
resources. (e.g., executive, judicial or legislative branch employees, grantees
or other recipients). Waste goes beyond fraud and abuse and most waste
does not involve a violation of law. Waste relates primarily to
mismanagement, inappropriate actions and inadequate oversight. – From the
Inspector General

10/16/2009 3
 Medicaid Integrity Program
Functions
„ Conducting and supervising activities to prevent,
detect and investigate Medicaid fraud, waste and
abuse.
„ Receiving and investigating complaints of Medicaid
alleged fraud, waste and abuse from individuals,
beneficiaries and providers.
„ Provider Audits
„ Data Mining Activities
„ Explanation of Benefits to verify service performed
„ Data Runs for the Attorney General’s Office
10/16/2009 4
 MIP Functions Continued

„ Managed Care Site Visits

„ Beneficiary Monitoring Program – currently 125
beneficiaries enrolled
„ Contract Oversight
° Hospital Audits & Utilization Review
° Pharmacy Audits
„ Alleged Health Care Fraud Referrals to the Attorney
General Office and the Office of the Inspector
General
10/16/2009 5
 Examples of Medicaid Fraud & Abuse
committed by Providers
„ Billing for medical services not actually performed
„ Providing unnecessary services
„ Billing for more expensive services than what were
provided
„ Billing more than once for the same medical service
„ Dispensing generic drugs but billing for brand-name
drugs to Medicaid
„ Kickbacks – accepting something of value in return
for medical services
„ Billing for services separately that should
legitimately be a combination/packaged code
10/16/2009 6
 Examples of Medicaid Fraud &
Abuse committed by
Beneficiaries/Individuals’
When someone :
„ Lies about their assets/income to obtain eligibility

„ Lies about their medical condition

„ Forges prescriptions

„ Sells their prescription drugs to others

„ Loans their Medicaid card to others

10/16/2009 7
 Medicaid Integrity Potential Outcomes:
Program
Initiate Audit

Initiate gross adjustment

process
Complaints/ (Recover overpayments)
Referrals SURS
•Phone Profile Provider self-review
•E-mail Episodes of Care
•Mail Spike Referrals to:
•Web
*Other law
enforcement
agencies

Preliminary analysis *Bureau of

Health Professions

*CMS

*BMP

Data mining EOB *HCFD

Activities *Recurring standard
*Recurring queries *Targeted *Managed
*Ad Hoc care

10/16/2009 8
 Emerging Trends In The
Medicaid Integrity Program
„ Monitor unusual claim volumes or spikes in payments
„ Explore upfront edits for prospective fraud in addition
to retrospective
„ Continued development of the MIP web site
www.michigan.gov/fraud
„ Collaborate with stakeholders to identify vulnerable
areas within a specific program, clarifying policy or
creating new edits
10/16/2009 9
 Emerging Trends Continued

„ To the greatest extent possible, continue working in

a coordinated and cooperative manner with:
° The Attorney General’s Medicaid Fraud
Control Unit (MFCU)
„ Continued focus on the provider enrollment
processes
„ Ensure adequate provider education
„ Utilize provider self reviews
„ Encourage voluntary disclosures

10/16/2009 10
 Where & How Do I Report An
Alleged Fraud Complaint
„ Medicaid Integrity Program Phone numbers:
° 1-866-428-0005 – toll free
° 517-335-5239
„ Send a letter to:
Medicaid Integrity Program
400 S. Pine St., 6th Floor
Lansing, MI 48909
„ Submit an Online Complaint Form at:
www.michigan.gov/fraud
Click on Submit an online complaint form
10/16/2009 11