Medicaid Integrity Program Provider Audits (MIP)
Under the Deficit Reduction Act (DRA) of 2005, Congress directed the Centers for Medicare & Medicaid Services (CMS) to establish the Medicaid Integrity Program (MIP).
Section 1936 of the Social Security Act (the Act) requires CMS to contract with eligible entities to review and audit Medicaid claims, to identify overpayments, and to provide education on program integrity issues. The ACT also requires CMS to provide effective support and assistance to states to combat provider fraud and abuse.
Medical Review & Audits
Medicaid Integrity Contractors (MICs)
The Medicaid Integrity Contractors (MICs) are private companies that conduct audit-related activities under contract to the Medicaid Integrity Group (MIG). CMS has divided the country into regions, each with their own MIC. Utah is in Regions VI/VIII, along with Arkansas, Colorado, Louisiana, Montana, North Dakota, New Mexico, Oklahoma, South Dakota, Texas, and Wyoming.
Recovery Audit Contractor (RAC) Program
Under Section 1902(a)(42)(B)(i) of the Act, States and Territories are required to establish programs to contract with one or more Medicaid RACs for the purpose of identifying underpayments and overpayments and recouping overpayments made to providers by the Medicaid Program.
CMS issued a letter to State Medicaid Directors on October 1, 2010, providing preliminary guidance to States on the implementation of their RAC programs.
Clarification from the Centers for Medicare & Medicaid Services (CMS) expectations for State implementation of Medicaid RAC programs. Section 6411 of the Affordable Care Act, Expansion of the Recovery Audit Contractor (RAC) Program, required States to establish programs to contract with RACs to audit payments to Medicaid providers by December 31, 2010.
Payment Error Rate Measurement (PERM)
The Centers for Medicare & Medicaid Services (CMS) implemented the Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the Children's Health Insurance Program (CHIP). PERM is designed to comply with the Improper Payments Information Act of 2002 (IPIA; Public Law 107-300). Utah Medicaid is currently in their second PERM review. Utah is in their second PERM review for Federal Fiscal Year 2010.
Utah OIG Program Integrity Reviews and Audits
The Utah OIG is responsible to ensure fiscal integrity of the Utah Medicaid program while meeting the healthcare needs of the many Medicaid beneficiaries.
One way to accomplish this is to reduce improper payments made to Medicaid providers and to identify fraud, waste and abuse in all aspects of the Medicaid program. This is done by reviewing provider claims, Medicaid policies and procedures, Medicaid contracts, and focusing on programs and services where fraud, waste and abuse are most vulnerable.