Program Integrity (PI) receives complaints and referrals from Medicaid recipients, their families, providers, the public, and through various federal and state agencies. PI pursues each referral of suspected fraud, waste & abuse it receives and uses the information to open investigations. 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 Program Integrity for investigation.
What is Medicaid Provider (Public Assistance) Fraud?
Examples of Public Assistance Fraud:
Billing a doctor, hospital or health care professional 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 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.
New Attorney General for OIG
Michael Green comes to us from Thomas Jefferson Law School. Since 2011 Michael was in charge of policy and training
John Slade was awarded the Governor's Award for Excellence in Leadership for the State of Utah
OIG goes under DAS
Due to the recent HB 106, OIG is now under the Department of Administrative Services and no longer under the Governor's office.