Reporting Suspected Fraud, Waste & Abuse
Do I have to give my name when reporting Medicaid fraud?
What type of information do I need to give when reporting fraud?
What type of fraud and abuse do you investigate?
I don’t think my provider is giving me the care I need? Who investigates quality of care?
Who investigates Recipient fraud, waste and abuse?
Why should I report Medicaid fraud or abuse?
No, you are not required to give any personal information. Your referral can be anonymous.
The more information you can give the better.
Medicaid provider fraud, waste and abuse. To make a report, call the Program Integrity Hotline at 855-403-7283, or [CLICK HERE] to fill out an online referral form online.
The Utah Division of Occupational and Professional Licensing (DOPL). If you need to report a quality of care concern, call 801- 530-6628 or e-mail email@example.com.
The Department of Workforce Services Payment Error Prevention Unit. If you think someone is getting Medicaid benefits they should not, call DWS Hotline at 1-800-955-221 or e-mail firstname.lastname@example.org.
Audit & Reviews
How far back can Medicaid provider claims be audited?
Are there any Medicaid provider types which are not subject to audit?
How long will the provider be given to produce the records?
Who pays for the cost of copying the medical records?
How many times can a Medicaid provider expect to be audited?
What is CMS?
What are the MICs?
Are the Audit MICs responsible for collecting overpayments?
What Federal statute established the MIP and authority to conduct Medicaid provider reviews and audits?
What Federal regulations exist with respect to the MICs?
The regulations on entities eligible to be MICs and on the limitation of MIC liability can be found at 42 CFR § 455.230 and 455.202, respectively.
How does the MIG avoid duplicating other Medicaid audits?
Are the MICs involved in deciding which provider claims are paid or adjudicated?
Does CMS Integrity Contractor share Audit MIC audit reports with anyone other than the provider who is being audited?
Utah Program Integrity generally looks back three to five years. The Audit MICs follow a five year audit look-back period.
No, all provider types are subject to audit.
As a general rule, a provider will have thirty (30) days to submit medical records.
CMS or the Audit MICs do not reimburse the provider for the cost of copying medical records. Program Integrity or the State Medicaid program will reimburse the provider upon request the cost of making copies of records at a rate not to exceed 10 cents per copy when there are 20 or more pages to be copied.
There are different groups that conduct audits, such as the Audit MIC, Program Integrity, Recovery Audit Contractors (RACs), or the Inspector General’s of the State or the U.S. Department of Health & Human Services. It is possible that you may be audited more than once. Program Integrity reviews the requests from other auditing groups, and tries to minimize the impact on providers and limit the number of audits.
The Centers for Medicare & Medicaid Services (CMS) is a branch of the United States Department of Health & Human Services. CMS is the federal agency that administers the Medicare program and monitors the Medicaid programs offered by each state.
The Medicaid Integrity Contractors (MICs) are private companies that conduct audit-related activities under contract to the Medicaid Integrity Group (MIG), the component within CMS that is charged by the U.S. Department of Health & Human Services with carrying out the Medicaid Integrity Program (MIP).
No. Program Integrity is responsible for collecting overpayments from providers. This is done in accordance with Utah laws, regulations, and procedures.
The Deficit Reduction Act of 2005, signed into law on February 8, 2006, created the Medicaid Integrity Program. The statutory authority for the Medicaid Integrity Program is in Section 1936 of the Social Security Act (42 U.S.C. § 1396u-6).
They vet providers to be audited with the Utah Program Integrity group prior to the start of the audits. The MIG also shares the list of potential audits with State and Federal law enforcement agencies. If either a State Medicaid agency or a law enforcement agency is conducting an audit or investigation of the same provider for similar Medicaid issues, then the MIG may cancel or postpone their audit of the provider.
The Audit MICs support the Utahs' adjudication and collection efforts by providing necessary documents, information, and testimony.
Yes. The Audit MIC audit reports are shared with the State Medicaid agency. However, as required by law, the reports may also be shared with Federal or State law enforcement agencies.