The Utah Office of Inspector General of Medicaid Services (UOIG) conducts oversight of the Utah Medicaid program pursuant to Utah Code Title 63A, Chapter 13. The mission of UOIG is to provide oversight and monitoring of the Medicaid program to identify and recover improper payments and to make recommendations to the Utah Department of Health on ways to improve program operations and management. The UOIG conducts investigations and reviews of Medicaid claims to identify possible improper payments. Improper payments are categorized as errors, waste, abuse, or fraud. Utah Code 63A-13-102 provides the following important definitions:
Abuse: An action or practice that is inconsistent with sound fiscal, business, or medical practices; and results, or may result, in unnecessary Medicaid related costs; or reckless or negligent upcoding.
Fraud: Intentional or knowing: (a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or (b) a violation of a provision of Sections 26-20-3 through 26-20-7.
Waste: Overutilization of resources or inappropriate payment.
Upcoding: Assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement.
The Centers for Medicare and Medicaid Services (CMS) provides additional guidance to further understand the scale of improper Medicaid payments:
– Errors are simple mistakes made on a claim. Errors can be combined into waste, but have been broken out by CMS as the most simple and unintentional act that results in an overpayment.
– Waste can be inefficiencies within the submission or processing of claims. There is no intentional act to deceive or misrepresent facts.
– Abuse is the bending of the rules to achieve a higher than allowed payment. This may be such things as providing unnecessary services or those that do not meet standards of care. This may
also be a recipient that causes unnecessary services to be provided.
– Fraud is an intentional act or deception. It is a misrepresentation of the facts. This can include concealment of information.
It is important to know that the vast majority of all improper payments are unintentional errors. Errors can happen because a provider or one of their staff simply do not fully understand Medicaid policies. Training can help resolve those misunderstandings and help providers better participate in the Medicaid program.
To report suspected provider or recipient fraud, waste or abuse, or to request training from the UOIG, please contact us at (801) 538-6087.
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