The Utah Office of Inspector General (UOIG) may request medical records as part of the oversight mission for Medicaid. It is important for providers to submit a complete and legible copy of all medical records including chart notes, orders, detail itemized claims and all other documentation relating to the treatment, services and claims for the Medicaid recipient, when requested. In the event that the UOIG does not receive a complete copy of all medical records within 30 days, the claim payment may be recovered for failure to substantiate that services were provided in accordance with Utah Medicaid policies and rules. The UOIG relies upon policy and rules found in the following:

1. Section I: General Information Provider Manual, Chapter 4;
“Promptly disclose or furnish all information regarding any payment claimed for providing Medicaid services upon request by the State and its designees, including the Office of Inspector General (OIG) and the Medicaid Fraud Control Unit, or the Secretary of the United States Department of Health and Human Services.”

2. Section I: General Information Provider Manual, Chapter 8-1:
“Medical services will be of a quality that meets professionally recognized standards of health care, and will be substantiated by records including evidence of such medical necessity and quality. Those records will be made available to the Medicaid upon request.”

3, Utah Administrative Code Rule R30-1-8b:
“(1) In order to fulfill the duties described in Section 63A-13-202, the Office shall have unrestricted access to all records of state executive branch entities, all local government entities, and all providers relating, directly or indirectly, as stated in 63A-13-301. (2) The Office shall request access to records or documents through a written request. The responding agency or entity must respond to the request within 30 days.”

3. Provider Agreement for Medicaid:
“PROVIDER agrees to provide reasonable access to all requested records relevant to claims submitted for services furnished under any medical assistance programs for auditing and investigative purposes…”

The UOIG works to ensure the Medicaid program is successful and operates in accordance with policy, rules, regulations and laws. On method to ensure compliance with policies is to request and review records from providers. When this office requests medical records, please respond promptly and return a complete copy of all medical records within 30 days. Failure to do so may result in recovery of the paid claim.

If providers have questions regarding this policy or would like training from the UOIG, please contact the UOIG Training Coordinator at (801) 538-6018.

The HHS OIG List of Excluded Individuals and Entities (LEIE) has been updated with April 2017 exclusions and reinstatements. This database was updated and published by HHS OIG on 08 May 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].

The Utah Office of Inspector General (UOIG) is an independent government agency tasked by statute to conduct oversight of the Utah Medicaid program. This includes oversight of all programs, funding and services associated directly or indirectly with Medicaid.

The office conducts oversight of the Medicaid program using several diverse and wide-ranging tools and resources: Audits, Inspections, Investigations, Monitoring, Education and Training, and Policy Reviews.

UOIG is able to make recommendations to Medicaid about how to improve operations and efficiency of the program. The office works to identify, prevent and recover taxpayer monies that are expended as the result of improper payment or fraud, waste and abuse.”

The office recently provided a training at the Adult Protective Services Division within the Utah Department of Human Services. Click here for the training slides presented.

Utah Office of the Inspector General (UOIG) is pleased to announce that Mr. Neil Erickson has been promoted to serve as the office’s new Audit Manager. Neil has been a member of the UOIG since 2015 where he has served in an Auditor IV position. He has over 24 years of auditing, financial, and accounting experience that has culminated into a unique and highly valuable skill-set for the office. He has a proven track record in conducting highly complex audits that have directly resulted in improvements to the Utah Medicaid program. As the new UOIG Audit Manager, Neil will oversee all aspects of the Audit Department that includes management of five audit positions. Through Neil’s leadership, the Audit Department will strive to better identify and prevent fraud, waste and abuse within the Medicaid Program. The UOIG takes great pleasure in recognizing Neil’s exceptional talents by placing him in a leadership position that will further the Office’s mission to conduct oversight of the Medicaid program.

The Federal Office of Inspector General (OIG) for the U.S. Department of Health & Human Services (HHS) is tasked with maintaining a database containing a list of individuals and entities that are excluded from participation in Medicare, Medicaid, and other federally funded health care programs. This database of excluded individuals and entities is known as the List of Excluded Individuals/Entities or LEIE. Persons or entities that are listed on the LEIE cannot participate in the Utah Medicaid program and cannot be employed in certain jobs and functions within a provider’s office that is enrolled in the Utah Medicaid program. Providers enrolled in Utah Medicaid cannot employ persons on the LEIE even if they are not directly providing care to Medicaid patients. An individual on the exclusion list cannot serve in a leadership position, and cannot provide administrative or management services, such as health information technology services and support, strategic planning, billing and accounting, staff training, and human resources.

If a Utah Medicaid provider employs an excluded individual or entity in these roles, those Medicaid payments will be recovered and the provider risks having additional assessments and penalties imposed on them. Providers must be aware of the importance of this exclusion rule and must take steps to ensure they do not improperly employ an excluded individual. Utah Medicaid publishes this exclusion policy within the Utah Medicaid Section I: General Information Provider Manual which can be viewed at: https://medicaid.utah.gov/utah-medicaid-official-publications.

For additional information about the HHS OIG exclusion rule, please visit: https://oig.hhs.gov/faqs/exclusions-faq.asp. It is recommended that all providers participating in the Utah Medicaid program conduct regular checks of the LEIE to ensure they are not improperly employing an excluded individual or entity. The LEIE is updated monthly with new exclusion and reinstatement files. You may contact the Utah Office of the Inspector General Policy and Training Coordinator at (801) 538-6018 with additional questions and for providers to request training on the LEIE and Utah Medicaid exclusion policy.

The Utah Attorney General’s Office recently charged a Medicaid provider with communications fraud and engaging in a pattern of unlawful activity. This case involved a Medicaid provider that was contracted to provide counseling services to incarcerated juveniles. Richard J. Garcia, a Licensed Clinical Social Worker, falsified billing records and submitted fraudulent claims to the state totaling at least $100,000.

The Utah Office of the Inspector General (UOIG) worked with partner agencies, including the Utah Attorney General’s Office, in identifying suspected claims submitted by Garcia. The UOIG utilized sophisticated data analysis systems and investigation techniques to identify abnormalities in Garcia’s billings. Once UOIG investigators were able to identify suspected fraudulent activity, the office worked with partner agencies in referring the case to the Utah Attorney General’s Office for further investigation and possible criminal charges.

With the announcement that charges have been filed against Garcia, taxpayers are further realizing the success of the UOIG in identifying fraud, waste, and abuse within the Medicaid system. The case of Garcia highlights the importance of maintaining a strong oversight activity for the Medicaid program. The UOIG conducts oversight of the program through audits, inspections, investigations, claims reviews, random sampling, and proprietary data analysis. For further information about the UOIG or to report suspected fraudulent activity, please contact us at (801) 538-6087.

On October 19th, the Utah Office of the Inspector General (UOIG) submitted its 2016 Annual Report to the Governor, Speaker of the House, Senate President and to the Executive Appropriations Committee. This is the sixth fiscal year that the UOIG has conducted oversight operations of the Medicaid program. Additionally, July 1, 2016 marked the fifth successful year of UOIG service to the citizens of Utah. For 2016, the UOIG successfully collected $8,031,309, representing a taxpayer return on investment of 307%. An additional estimated $5.2 million was protected from inappropriate expenditure through a concept known as “Cost Avoidance.” These Cost Avoidance and Collections measures resulted in a combined return on taxpayer investment of 506%; a substantial savings to the taxpayers of Utah. In addition to these successes, the UOIG referred a greater number of fraud cases to Medicaid Fraud Control Unit than any previous year of operations. The UOIG has also improved partnership building through training, education, and outreach programs. The full UOIG 2016 Annual Report is available on the Office’s website and by clicking on the following link. For more information and media inquiries, please contact UOIG Public Information Officer at (385) 831-5397.

The Utah Office of Inspector General (UOIG) continues to develop and strengthen partnerships with Medicaid, the provider community, Accountable Care Organizations (ACOs) and the Medicaid Fraud Control Unit (MFCU).  Most recently, the UOIG hosted a training and information sharing conference to discuss current issues, lessons learned and best practices with ACO and MFCU representatives.  These conferences are held quarterly and have proven to be a valuable tool to build upon already great relationships. Through strong partnerships, the UOIG is able to improve its ability to identify and prevent fraud, waste and abuse within the Medicaid program.  This is one of the many programs that have proven to be successful in protecting taxpayer resources and improving the Medicaid program for the benefit of recipients, the provider community, and citizens of Utah.  Click here for the training slides.  For more information about the UOIG and its programs to identify and prevent fraud, waste and abuse, please contact UOIG Public Information Officer at (385) 831-5397.

The Utah Office of the Inspector General (UOIG) is pleased to announce that Mr. Nathan Johansen has been retained to serve as the Deputy Inspector General for the UOIG. Mr. Johansen will serve directly under Inspector General Gene Cottrell. This new position, a first for the office, will reinforce the UOIG mission with strong, capable and experienced leadership. Mr. Johansen’s background as a senior auditor with over 12 years of extensive auditor experience, will be a great benefit to the UOIG and the taxpayers of the State of Utah. His broad and diverse background, and knowledge of Medicaid, will ensure the UOIG will continue to serve the people of Utah through solid oversight of program operations.

The Utah OIG, in partnership with Utah Medicaid representatives, have completed the 2016 Statewide Medicaid Provider Training circuit. For 2016, a total of 29 Provider Training Sessions were completed throughout the State of Utah. Five new locations were added to the 2016 schedule to include the Intermountain Medical Center in Murray, Lakeview Hospital in Bountiful, St. Mark’s Hospital in Salt Lake City, Bear River Health Department in Tremonton, and the Delta Community Hospital in Delta. Training topics included helpful tips on billing, common billing errors, important changes to the Medicaid program, new updates to the provider portal, and updates on the Provider Reimbursement Information System for Medicaid (PRISM) project. OIG specific topics included background on the creation of the OIG office, tools and resources used in the oversight of the Medicaid program, local and national trends, lessons learned, guidance and a focus on continued partnership development with Medicaid and the provider community.

In addition to partnering with Utah Medicaid for the Statewide Provider Training, the Utah OIG also provides training and guidance to providers and Medicaid representatives on an as needed or requested basis. Providers are welcome to reach out to the OIG to request guidance, training and support on various Medicaid-OIG operations that further the OIG mission to support and protect taxpayer dollars and resources as intended by the legislature in creating the office.