The Utah OIG Special Investigations Unit (SIU) performs the Program Integrity (PI) functions for the Utah Medicaid Program. The SIU receives complaints and referrals from Medicaid recipients, their families, providers, the public, and through various federal and state agencies. SIU pursues each referral of suspected fraud, waste & abuse it receives, and uses the information to open investigations as appropriate. Utah Program Integrity investigates provider fraud, waste, & abuse in all aspects of the Utah Medicaid Program. Any Medicaid recipient, health care provider or private citizen may report suspected provider fraud, waste, & abuse to the Utah OIG for investigation.
What is Medicaid Provider Fraud?
Examples of Provider Fraud:
A doctor, hospital or health care professional billing for Medicaid services before the treatment is done or completed.
Billing for patients who did not receive services by the provider, known as "phantom patients."
Billing for services that are not medically necessary or required by the patient.
Billing for a higher level of service than was actually rendered by the provider, known as "up-coding."
What is Medicaid Recipient (Public Assistance) Fraud?
Public Assistance includes:
Medicaid medical services
It is considered Recipient fraud when a person:
Uses another Medicaid recipient's card with or without their knowledge.
Loans a Medicaid ID card to other people.
Uses more than one Medicaid identification card.
Doctor shops to get multiple services or prescriptions.
Forges or changes a prescription.
Does not use items received through the Medicaid program as intended.
Sells medical items and supplies for profit.
Asks for and receives services or supplies that are not needed.
Helpful Information to Know...
When Reporting Fraud, Waste, & Abuse
Before making your referral, gather as many facts as possible. Useful information can include:
Medicaid Recipient or Rendering Provider's Name
Date of Birth (Recipient)
Medicaid Recipient or Provider ID Number
Social Security Number
Other details regarding suspicious or what appears to be inappropriate.
It has been another productive year for the Utah OIG, which released its fiscal year (FY) 2014 annual report, showing $11,570,604 of inappropriately paid Medicaid funds. This is a recovery rate of $5 for every $1 spent.
In compliance with Utah Code § 63A-13-502, the Utah Office of the Inspector General (Utah OIG) releases its fiscal year (FY) 2014 Annual Report.
New Assistant Attorney General for Utah OIG
We would like to welcome Lana Taylor to the Utah OIG team. Lana has been an Assistant Attorney General at the Utah Attorney General’s Office for nearly 10 years. Prior to coming to the Utah OIG, she was in the AG's Criminal Justice Division where she worked in the Special Prosecutions and Insurance Fraud Sections as well as with the Utah Department of Public Safety. We look forward to partnering with Lana going forward.