Do I have to give my name when reporting Medicaid fraud?
No, you are not required to give any personal information. Your referral can be anonymous. However, it can be helpful to the investigator on the case to have your name and number for contact purposes, if you are comfortable leaving that information.
What type of fraud and abuse do you investigate?
Medicaid provider fraud, waste and abuse is the focus of the Utah Office of Inspector General (Utah OIG). To make a report, call the Special Investigations Hotline at 1-855-403-7283, email firstname.lastname@example.org or click here to fill out a referral form online.
Who investigates recipient fraud, waste and abuse?
The Department of Workforce Services Payment Error Prevention Unit investigates recipient fraud claims. If you think someone is getting Medicaid benefits they should not receive, either call the DWS Hotline at 1-800-955-2210, e-mail email@example.com, or click here to fill out a referral form online.
Why should I report Medicaid fraud or abuse?
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.
What type of information can I give when reporting fraud?
Medicaid Recipient Name
Date of Birth
Medicaid Recipient ID Number
Social Security Number
Other details about what you suspect may be happening that appears to be wrong.
Medicaid Integrity Progam (MIP) and Post Payment Reviews
How far back can Medicaid provider claims be reviewed?
The Utah Office of Inspector General (Utah OIG) generally looks back three years from the inception of a review. The Audit MICs (Medicaid Integrity Contractors) follow CMS guidelines.
Are there any Medicaid provider types which are not subject to audit?
No, all Medicaid Contracted provider types are subject to audit.
How long will the provider be given to produce the records?
As a general rule, a provider will have thirty (30) days to submit comprehensive medical records.
Who pays for the cost of copying the medical records?
CMS or the Audit MICs do not reimburse the provider for the cost of copying medical records. Reimbursement for photocopying is paid by the Utah OIG and the Utah State Medicaid
program at a rate of $.10 per page, when more than twenty (20) pages are copied. The first 20 pages are the responsibility of the provider. A statement for payment must be submitted by the medical records department and must accompany the requested record.
How many times can a Medicaid provider expect to be audited?
There are different groups that conduct audits, such as the Audit MIC, Program Integrity, Recovery Audit Contractors (RACs), the Federal/State Inspector General’s or the U.S. Department of Health and Human Services. It is possible that you may be audited more than once per claim. The Utah OIG Special Investigations Unit reviews the requests from other auditing groups, and tries to minimize the impact on providers and limit the number of audits to the best of their ability.
What is CMS?
The Centers for Medicare and Medicaid Services (CMS) is a branch of the United States Department of Health and Human Services. CMS is the federal agency that administers the Medicare program and monitors the Medicaid programs offered by each state.
What are the MICs?
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 and Human Services with carrying out the Medicaid Integrity Program (MIP), which the Utah OIG oversees.
Are the Audit MICs responsible for collecting overpayments?
No. The Utah OIG, through the Medicaid Integrity Program (MIP), is responsible for collecting overpayments from providers. This is done in accordance with Utah laws, regulations, and procedures.
What Federal statute established the MIP and authority to conduct Medicaid provider reviews and audits?
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).
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?
The MIG vet providers to be audited with the Utah OIG Special Investigations Unit 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.
Are the MICs involved in deciding which provider claims are paid or adjudicated?
The Audit MICs support adjudication and collection efforts by providing necessary documents, information, and testimony; they submit their findings to the Utah OIG for consideration.
Does CMS Integrity Contractor share Audit MIC audit reports with anyone other than the provider who is being audited?
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.
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.