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Medicaid Program Integrity

 

What is Medicaid Program Integrity?

Medicaid Program Integrity is a system of reasonable and consistent oversight of the Medicaid program. Program Integrity effectively:

    • encourages compliance
    • maintains accountability
    • protects public funds
    • supports awareness and responsibility
    • ensures that providers meet participation requirements
    • ensures that services are medically necessary
    • ensures payments are for the correct amount and for covered services

The goal of Program Integrity is to reduce and eliminate fraud, waste, and abuse in the Medicaid Program.

Common functions of Program Integrity include prevention, investigation, education, audit, recovery of improper payments, and cooperation with Medicaid Fraud Control Units (MFCU).

Audits

For an overview of audits and reviews that affect providers who work with the Department of Health and Social Services visit Care Provider Audits.

What is Fraud and Abuse?

Fraud is defined by:

    The Code of Federal Regulations(42 CFR 455.2) as

    An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other persons. It includes any act that constitutes fraud under applicable Federal or State law.

    Alaska Statute (AS 47.05.210) as

    The crime of medical assistance [when a person] knowingly submits or authorizes the submission of a claim to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, services, or benefit;

Abuse is defined by the Code of Federal Regulations(42 CFR 455.2) as

    Provider practices that are inconsistent with sound fiscal, business, or medical, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Reporting Medicaid Provider Fraud

If you wish to report potential fraud by a provider, call the Medicaid Fraud Control Unit (MFCU) at 907.269.6279.

For more information visit MFCU.

Alaska Excluded Provider List

An excluded provider is one that has been formally sanctioned with termination by the State and/or Federal government. Any provider convicted of medical assistance fraud will be excluded from participating in the Medicaid program.

The Alaska Department of Health and Social Service Program Integrity Unit maintains a list of providers whose Medicaid provider agreements have been terminated due to sanction or conviction of fraud.

Any provider participating or applying to participate in the Medicaid program or hiring staff should review the excluded provider list and the LEIE on a routine basis to determine if an existing or potential employee or contractor has been excluded from participation in the Medicaid program.

For the current Alaska Excluded Provider List visit Alaska Excluded Provider List.

LEIE

The U.S. Department of Health & Human Services’ Office of Inspector General (OIG) also maintains a List of Excluded Individuals/Entities (LEIE) containing the names of those who are excluded from participation in federal and state health care programs. If an individual is on the LEIE, they are not allowed to receive reimbursement for Medicaid services in any capacity, even if they are not on the Alaska Excluded Provider List.

For more information visit the LEIE.

For all program review and quality assurance inquiries, contact:

Douglas Jones
Medicaid Program Integrity Manager
douglas.jones@alaska.gov
Phone: 907.269.0361
Fax: 907.269.3460

4601 Business Park Blvd, Building K
Anchorage, AK 99503-7167

P.O. Box 240249
Anchorage, AK 99524-0249