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SALT LAKE CITY – The Utah Office of Inspector General of Medicaid Services (Utah OIG) was created to protect the Utah Medicaid program through a variety of oversight operations such as auditing, investigations, inspections, monitoring, training and reviews of Medicaid policies. These oversight activities are intended to protect Utah taxpayers by ensuring providers follow established policies and by maximizing the efficient operation and management of the program. The Utah Medicaid program is an important resource to Utah that provides health care to vulnerable low income populations to include pregnant women, children, elderly, disabled, qualified parents and women with breast or cervical cancer.

During 2017, Utah OIG Investigator Kristan Hernandez instituted focused investigations into the proper billing of Medicaid patients to ensure these vulnerable populations were not improperly billed by providers. To help offset the cost of providing health care, some Medicaid recipients are required to pay cost-sharing amounts such as co-payments. These amounts are typically low, but can be a significant burden on a low income patient. Investigator Hernandez, during her “balance billing” focused investigations, discovered that a small number of Utah Medicaid patients were balance billed for amounts not authorized by policy. One patient was billed as much as $813 when there was no cost-sharing requirement associated with the service. The investigator learned that when some patients could not pay the bill, their account was turned over to collection. This compounded the financial burden on patients with the incurrence of attorney’s fees, costs and interest.

Investigator Hernandez discovered 15 Utah Medicaid providers that have balance billed some patients in violation of policy. During these investigations, Hernandez realized the majority of the providers simply did not understand that Medicaid policy prohibits balance billing. Providers overwhelmingly welcomed the opportunity to better comply with policies and quickly rescinded collection efforts. The investigations resulted in protection of Medicaid patients and the program through better education and awareness for providers. “Utah Medicaid providers want to be good partners to the program and want to comply with Medicaid policies. They have worked hard to correct any billing mistakes and have been open to receiving further training to stay strong partners to the program and community,” says Investigator Hernandez. When Utah OIG determines a provider could benefit from training, they are referred to the Policy & Training Coordinator who works with the providers to schedule and present training about Medicaid policy and operations of the Utah OIG.

As the result of these focused investigations, the Utah OIG has determined that balance billing is an increasing issue that negatively impacts recipients and the program. Utah OIG will continue to identify policy violations to protect recipients, the Medicaid program and taxpayers of Utah.

To learn more about Utah OIG, please visit us at or contact our Public Information Officer at (385) 831-5397.

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