Reporting Suspected Fraud, Waste & Abuse

  1. Do I have to give my name when reporting Medicaid fraud?
  2. No, you are not required to give any personal information. Your referral can be anonymous.

  3. What type of fraud and abuse do you investigate?
  4. Medicaid provider fraud, waste and abuse. To make a report, call the Program Integrity Hotline at 855-403-7283 to fill out an online referral form online.

  5. Who investigates recipient fraud, waste and abuse?
  6. The Department of Workforce Services Payment Error Prevention Unit investigates claims. If you think someone is getting Medicaid benefits they should not receive, call either the DWS Hotline at 1-800-955-221 or e-mail wsinv@utah.gov.

  7. Why should I report Medicaid fraud or abuse?
  8. If you suspect Medicaid fraud or abuse it is required by law that you report it. Every Medicaid dollar that is used inappropriately is one less dollar that can be used to help those Medicaid recipients in need. Unreported Medicaid fraud, waste and abuse can cost the taxpayers millions of dollars each year.

  9. What type of information can I give when reporting fraud?
    • Medicaid Recipient Name
    • Date of Birth
    • Address
    • Phone Number
    • Medicaid Recipient ID Number
    • Social Security Number
    • Employment Information
    • Other details about what you suspect may be happening that appears to be wrong.

Post Payment

  1. How far back can Medicaid provider claims be audited?
  2. The Office of Inspector General (OIG) generally looks back three years frp, the inception of an audit. The Audit MICs (Medicaid Integrity Trackers) follows CMS guidelines

  3. Are there any Medicaid provider types which are not subject to audit?
  4. No, all provider types are subject to audit.

  5. How long will the provider be given to produce the records?
  6. As a general rule, a provider will have thirty (30) days to submit comprehensive medical records.

  7. Who pays for the cost of copying the medical records?
  8. CMS or the Audit MICs do not reimburse the provider for the cost of copying medical records. OIG 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.

  9. How many times can a Medicaid provider expect to be audited?
  10. There are different groups that conduct audits such as the Audit MIC, Program Integrity, Recovery Audit Contractors (RACs) or the Federal/State Inspector General’s or the U.S. Department of Health Human Services. It is possible that you may be audited more than once per claim. Program Integrity reviews the requests from other auditing groups, and tries to minimize the impact on providers and limit the number of audits.

  11. What is CMS?
  12. 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.

  13. What are the MICs?
  14. 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).

  15. Are the Audit MICs responsible for collecting overpayments?
  16. No. Program Integrity is responsible for collecting overpayments from providers. This is done in accordance with Utah laws, regulations, and procedures.

  17. What Federal statute established the MIP and authority to conduct Medicaid provider reviews and audits?
  18. 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).

  19. What Federal regulations exist with respect to the MICs?
  20. 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.

  21. How does the MIG avoid duplicating other Medicaid audits?
  22. 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.

  23. Are the MICs involved in deciding which provider claims are paid or adjudicated?
  24. The Audit MICs support adjudication and collection efforts by providing necessary documents, information, and testimony; they submit their findings to the OIG for consideration.

  25. Does CMS Integrity Contractor share Audit MIC audit reports with anyone other than the provider who is being audited?
  26. 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.

  27. pdf Acronyms