Medicaid Program Integrity


What is Medicaid Program Integrity?

Program Integrity is a reasonable and consistent system of oversight of the Medicaid program which effectively encourages compliance; maintains accountability; protects public funds; supports awareness and responsibility; ensure providers meet participation requirements; services are medically necessary; and payments are for the correct amount and for covered services.  The end goal is to reduce and eliminate fraud, waste, and abuse in the Medicaid Program.

Common functions of Program Integrity include prevention; investigation; education; audit; recovery of improper payments, cooperation with Medicaid Fraud Control Units (MFCU).

What is Fraud and Abuse?

Fraud: (per CFR 433.304 and 455.2)
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 persons.  It includes any act that constitutes fraud under applicable Federal or State law.

Abuse: (per CFR 433.304 and 455.2)
Provider practices that are inconsistent with sound fiscal, business, or medical, 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 recipient practices that result in unnecessary cost to the Medicaid program.

False Claims Information

http://ag.ks.gov/taxpayer-protection/false-claims

Reporting Medicaid Provider Fraud

If you wish to report potential fraud by a provider, call the Medicaid Fraud and Abuse Division of the Attorney General’s office 1-866-551-6328 or 785-368-6220.

Terminated Provider List –

The Kansas Department of Health and Environment Division of Health Care Finance maintains a list of providers whose Medicaid provider agreement has been terminated.  Refer to KAR 30-5-60 for the reasons a provider’s participation may be terminated.

Termination List (.pdf)

Visit the LEIE and EPLS for a complete listing of those individuals excluded from receiving reimbursement for Medicaid services.  If an individual is on the LEIE or EPLS they are not allowed to receive reimbursement for Medicaid services in any capacity even if they are not on this terminated provider list maintained by DHCF.

Resources –

Code of Federal Regulations (CFRs) applicable to Program Integrity  (not an all inclusive list):

42 CFR 438 – Managed Care
42 CFR 455 – Program Integrity: Medicaid
42 CFR 456 – Utilization Control
42 CFR 1001 – Program Integrity – Medicare and State Health Care Programs
42 CFR 1002 – Program Integrity – State Initiated exclusions from Medicaid
42 CFR 1007 – State Medicaid Fraud Control Units

Office of Inspector General – List of Excluded Individuals/Entities (LEIE)
http://exclusions.oig.hhs.gov/

General Services Administration Excluded Parties List System (EPLS)
https://www.sam.gov/portal/public/SAM/

CMS Medicaid Integrity Program
http://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index.html?redirect=/MedicaidIntegrityProgram/

Attorney Generals Medicaid Fraud and Abuse Division 
http://ag.ks.gov/taxpayer-protection/medicaid-fraud

Attorney Generals Medicaid Fraud Division brochure
http://ag.ks.gov/docs/publications/medicaid-fraud-brochure.pdf?sfvrsn=6