Utah law requires that a health care professional, a provider, or a state or local government official or employee who becomes aware of fraud, waste, or abuse to report the fraud, waste, or abuse to the Utah Utah Office of Inspector General (UOIG) or Medicaid Fraud Control Unit (MFCU).

A person who reports fraud, waste or abuse to UOIG may request that the person’s name not be released in connection with the investigation. The person’s identity may not be released to any person or entity other than the UOIG, MFCU or law enforcement, unless a court orders that the person’s identity be released.

See Utah Code 63A-13-501 for more information: https://le.utah.gov/xcode/code.html

Many Medicaid recipients are required to enroll with a Managed Care Organization (MCO). An MCO that covers physical health care is called an Accountable Care Organization (ACO); one that covers behavioral health is a Prepaid Mental Health Plan (PMHP), and one that covers dental services is called a dental plan (only for those eligible for full dental coverage). Medicaid members enrolled in MCOs are entitled to the same Medicaid benefits as fee-for-service members. However, MCOs may offer more benefits and may have different prior authorization requirements than the Medicaid scope of benefits. A Medicaid member enrolled in an MCO must receive services through that plan with some exceptions called “carve-out services.”

Medicaid contracts with four ACOs to provide healthcare: HealthChoice of Utah, Healthy U, Molina Healthcare and SelectHealth Community Care.

Learn more about MCOs and ACOs by reviewing the Utah Medicaid Provider Manual, Section I: General Information:

Publications

Provided below is a list of the most common or frequent types of provider fraud:

Billing for Unnecessary Services or Items: Intentionally billing for medical services or items that are not necessary.
Billing for Services or Items Not Provided: Intentionally billing for services or items never provided.
Unbundling: Billing for multiple codes for a group of procedures covered in a global code
Upcoding: Billing a higher cost code than than the service that was actually provided
Card Sharing: Knowingly treating and claiming reimbursement for someone other than the eligible patient.
Collusion: Collaborating with patients to file false claims for reimbursement
Drug Diversion: Writing unnecessary prescriptions, or altering prescriptions, to obtain drugs for personal use or to sell them
Kickbacks: Offering or receiving payments for patient referrals for medical services or items”

CMS provides certain bounds around the definition of “credible allegation of fraud” at 42 C.F.R. § 455.2:

Generally, a “credible allegation of fraud” may be an allegation that has been verified by a State and that has indicia of reliability that comes from any source. A credible allegation of fraud, for example, could be a complaint made by an employee of a physician alleging that the physician is engaged in fraudulent billing practices, i.e., the physician repeatedly bills for services at a higher level than is actually justified by the services rendered to beneficiaries.

Upon the Utah Office of Inspector General (UOIG) review of the physician’s billings, the UOIG investigator may determine that the allegation has indicia of reliability and is, in fact, credible. Indicia of reliability means that there are signs, indications or circumstances that point to the existence of a given fact. If there are signs, indications or circumstances that seem to point to the existence of fraud, there is a credible allegation of fraud. The Medicaid fraud allegation tends to indicate it is probable.

When UOIG identifies a credible allegation of fraud or “potential criminal conduct, relating to Medicaid funds or the state Medicaid program” we refer the case to the Medicaid Fraud Control Unit (MFCU) or to law enforcement. Learn more by reading the CFR, CMS guidelines and the Utah OIG statute:

https://le.utah.gov/xcode/Title63A/Chapter13/63A-13.html?v=C63A-13_1800010118000101

Utah Medicaid providers are prohibited from billing patients. Medicaid providers must accept the payment from Medicaid as payment in full. Providers may not bill Medicaid patients for services that are covered under Medicaid or by a Managed Care Organization (MCO). There are strict exceptions to this policy. Prohibition on billing Medicaid patients policy is located in the Section I: General Information Provider Manual located online at: https://medicaid.utah.gov/utah-medicaid-official-publications.

If you or someone you know has been billed by a provider for a Medicaid covered service, please report that suspected violation of Medicaid policy to the Utah Office of Inspector General.

Utah Medicaid will be making substantial changes to the provider manuals. Medicaid will start moving policy from the provider manuals to the appropriate Utah Administrative Rule within R414, Health, Health Care Financing, Coverage and Reimbursement Policy. Providers will notice this move taking place over the next several quarters. Moving Medicaid policy to the Administrative Rules will allow providers the opportunity to review and comment on rule updates. Providers are encouraged to become familiar with the Administrative Rule, because Medicaid coverage policy will be relocated to the appropriate rule based on service coverage.

The manuals will also be streamlined. For example, ancillary services such as laboratory services and women’s services information will be in the Utah Medicaid Physician Services Provider Manual effective July 1, 2017. As part of the manual revision process, information regarding specific code coverage will be moved from the provider manuals to the Utah Medicaid Coverage and Reimbursement Lookup Tool. The provider manuals will continue to be a reference for criteria and reporting instructions. Providers are encouraged to become familiar with the updated rules and manuals noting changes in the structure, formatting, and content of the manuals. Providers are still required to follow coverage policy, criteria, and prior authorization (PA) requirements.

View the updated provider manuals here: https://medicaid.utah.gov/utah-medicaid-official-publications

Utah Medicaid recently published the July 2017 Medicaid Information Bulletin (MIB). This MIB contains important information about various changes to the Utah Medicaid policies and program. The July 2017 MIB consists of 32 Articles. You can read the latest Medicaid newsletter at:

https://medicaid.utah.gov/Documents/manuals/pdfs/Medicaid%20Information%20Bulletins/Traditional%20Medicaid%20Program/2017/July2017-MIB.pdf

All Medicaid providers should read these MIBs as they are published. They are a valuable resource to ensure a good understanding of the Medicaid program and to stay up-to-date with policy changes.

The HHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) has been updated with June 2017 exclusions and reinstatements. This database was updated and published by HHS OIG on 05 July 2017. Utah Medicaid providers should review the updated database at https://oig.hhs.gov/exclusions/index.asp.

For more information about the updated LEIE or questions about the Utah Medicaid policy regarding excluded individuals or entities, please contact the Policy and Training Coordinator at (801) 538-6018 or by email at: [email protected].

On this July 4th, Americans throughout the world will celebrate 241 years of freedom and independence. We will come together as one nation to commemorate the commitment to equality, freedom and the belief in Life, Liberty and the Pursuit of Happiness.

As we celebrate the freedoms we hold so dearly, let us remember the sacrifices that so many have made throughout our American history and continue to make to this day. Thousands of service members are currently deployed throughout the world so that we may celebrate our Independence Day. Let us also remember the families of those deployed service members that are standing the watch here at home so they may focus on the mission of protecting us from air, land and sea. With great humility and admiration, the Office of Inspector General thanks all service members, veterans and families for making this sacrifice for our nation. You have acted with great “fidelity and courage, as knowing that now the peace and safety” of this country has relied and for which we are indebted. Thank you for the sacrifice you have made so we may continue to commemorate our independence.

Happy Independence Day to all Americans.

Follow the Utah Office of Inspector General (UOIG) on its updated Twitter page under the user name @UtahOIG. You can connect with us on Twitter using this link: https://twitter.com/utahoig

We will be sharing timely and important information about our office to include training opportunities, oversight activity, news, changes to Medicaid policies and other useful information that will be of interest to the Utah Medicaid provider community, our partners, and the taxpayers of Utah. We strive to be transparent and Twitter provides an additional resource to help accomplish that goal.

Reach out to us on Twitter to learn more about UOIG.