Michigan Medicaid Integrity Program

8/9/2019 Michigan Medicaid Integrity Program

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WHAT IS THE MEDICAIDWHAT IS THE MEDICAIDINTEGRITY PROGRAM ?INTEGRITY PROGRAM ?

October 2009October 2009


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WhoWho Are We?Are We?

The Medicaid Integrity Program (MIP) auditsThe Medicaid Integrity Program (MIP) audits

and investigates Medicaid providers andand investigates Medicaid providers and

Medicaid beneficiaries suspected of misusingMedicaid beneficiaries suspected of misusingMichigans Medicaid program. MIP worksMichigans Medicaid program. MIP works

to ensure that Medicaid money spent is usedto ensure that Medicaid money spent is used

for the best care of the beneficiaries.for the best care of the beneficiaries.


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Fraud, Waste, and AbuseFraud, Waste, and Abuse

FraudFraud IntentionalIntentional deception or misrepresentation made by a person withdeception or misrepresentation made by a person withthe knowledge that the deception could result in some unauthorizthe knowledge that the deception could result in some unauthorized benefited benefitto himself or some other person. It includes any act that constto himself or some other person. It includes any act that constitutes frauditutes fraudunder applicable Federal or State law. 42CFRunder applicable Federal or State law. 42CFR455.2455.2

AbuseAbuse Provider practices that are inconsistent with sound fiscal, busProvider practices that are inconsistent with sound fiscal, business,iness,or medical practices, and result in an unnecessary cost to the Mor medical practices, and result in an unnecessary cost to the Medicaidedicaidprogram, or in reimbursement for services that are not medicallyprogram, or in reimbursement for services that are not medically necessarynecessaryor that fail to meet professionally recognized standards for heaor that fail to meet professionally recognized standards for health care. Itlth care. It

also includes beneficiary practices that result in unnecessary calso includes beneficiary practices that result in unnecessary c

ost to theost to the

Medicaid program. 42CFRMedicaid program. 42CFR455.2455.2

WasteWaste Involves the taxpayers not receiving reasonable value for moneInvolves the taxpayers not receiving reasonable value for money iny inconnection with any government funded activities due to an inappconnection with any government funded activities due to an inappropriateropriateact or omission by players with control over or access to governact or omission by players with control over or access to governmentment

resources. (e.g., executive, judicial or legislative branch emplresources. (e.g., executive, judicial or legislative branch employees, granteesoyees, granteesor other recipients). Waste goes beyond fraud and abuse and mostor other recipients). Waste goes beyond fraud and abuse and most wastewastedoes not involve a violation of law. Waste relates primarily todoes not involve a violation of law. Waste relates primarily tomismanagement, inappropriate actions and inadequate oversight.mismanagement, inappropriate actions and inadequate oversight. From theFrom theInspector GeneralInspector General


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Medicaid Integrity ProgramMedicaid Integrity Program

FunctionsFunctions Conducting and supervising activities to prevent,Conducting and supervising activities to prevent,

detect and investigate Medicaid fraud, waste anddetect and investigate Medicaid fraud, waste andabuse.abuse.

Receiving and investigating complaints of MedicaidReceiving and investigating complaints of Medicaid

alleged fraud, waste and abuse from individuals,alleged fraud, waste and abuse from individuals,beneficiaries and providers.beneficiaries and providers.

Provider AuditsProvider Audits

Data Mining ActivitiesData Mining Activities

Explanation of Benefits to verify service performedExplanation of Benefits to verify service performed

Data Runs for the Attorney Generals OfficeData Runs for the Attorney Generals Office


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MIP Functions ContinuedMIP Functions Continued

Managed Care Site VisitsManaged Care Site Visits

Beneficiary Monitoring ProgramBeneficiary Monitoring Program currently 125currently 125beneficiaries enrolledbeneficiaries enrolled

Contract OversightContract Oversight

Hospital Audits & Utilization ReviewHospital Audits & Utilization Review

Pharmacy AuditsPharmacy Audits

Alleged Health Care Fraud Referrals to the AttorneyAlleged Health Care Fraud Referrals to the AttorneyGeneral Office and the Office of the InspectorGeneral Office and the Office of the Inspector

GeneralGeneral


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Examples of Medicaid Fraud & AbuseExamples of Medicaid Fraud & Abuse

committed by Providerscommitted by Providers

Billing for medical services not actually performedBilling for medical services not actually performed

Providing unnecessary servicesProviding unnecessary services

Billing for more expensive services than what wereBilling for more expensive services than what wereprovidedprovided

Billing more than once for the same medical serviceBilling more than once for the same medical service

Dispensing generic drugs but billing for brandDispensing generic drugs but billing for brand--namenamedrugs to Medicaiddrugs to Medicaid

KickbacksKickbacks accepting something of value in returnaccepting something of value in returnfor medical servicesfor medical services

Billing for services separately that shouldBilling for services separately that should

legitimately be a combination/packaged codelegitimately be a combination/packaged code


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Examples of Medicaid Fraud &Examples of Medicaid Fraud &

Abuse committed byAbuse committed byBeneficiaries/IndividualsBeneficiaries/Individuals

When someone :When someone :

Lies about their assets/income to obtain eligibilityLies about their assets/income to obtain eligibility Lies about their medical conditionLies about their medical condition

Forges prescriptionsForges prescriptions

Sells their prescription drugs to othersSells their prescription drugs to others

Loans their Medicaid card to othersLoans their Medicaid card to others


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Medicaid IntegrityProgram

Preliminary analysis

Complaints/ReferralsPhoneE-mail

MailWeb

SURSProfile

Episodes of Care

Spike

Data miningActivities

*Recurring queries*Ad Hoc

EOB*Recurring standard

*Targeted

Potential Outcomes:

Initiate Audit

Initiate gross adjustmentprocess

(Recover overpayments)

Provider self-review

Referrals to:

*Other lawenforcement

agencies

*Bureau ofHealth Professions

*CMS

*BMP

*HCFD

*Managedcare


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Emerging Trends In TheEmerging Trends In The


Monitor unusual claim volumes or spikes in paymentsMonitor unusual claim volumes or spikes in payments Explore upfront edits for prospective fraud in additionExplore upfront edits for prospective fraud in addition

to retrospectiveto retrospective

Continued development of the MIP web siteContinued development of the MIP web site

www.michigan.gov/fraudwww.michigan.gov/fraud

Collaborate with stakeholders to identify vulnerableCollaborate with stakeholders to identify vulnerableareas within a specific program, clarifying policy orareas within a specific program, clarifying policy or

creating new editscreating new edits


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Emerging Trends ContinuedEmerging Trends Continued

To the greatest extent possible, continue working inTo the greatest extent possible, continue working ina coordinated and cooperative manner with:a coordinated and cooperative manner with:

The Attorney GeneralThe Attorney Generals Medicaid Frauds Medicaid FraudControl Unit (MFCU)Control Unit (MFCU)

Continued focus on the provider enrollmentContinued focus on the provider enrollmentprocessesprocesses

Ensure adequate provider educationEnsure adequate provider education

Utilize provider self reviewsUtilize provider self reviews Encourage voluntary disclosuresEncourage voluntary disclosures


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Where & How Do I Report AnWhere & How Do I Report An

Alleged Fraud ComplaintAlleged Fraud Complaint Medicaid Integrity Program Phone numbers:Medicaid Integrity Program Phone numbers:

11--866866--428428--00050005 toll freetoll free 517517--335335--52395239

Send a letter to:Send a letter to:


400 S. Pine St., 6400 S. Pine St., 6thth FloorFloor

Lansing, MI 48909Lansing, MI 48909 Submit an Online Complaint Form at:Submit an Online Complaint Form at:

www.michigan.gov/fraudwww.michigan.gov/fraud

Click onClick on Submit an online complaint formSubmit an online complaint form
http://www.michigan.gov/fraudhttp://www.michigan.gov/fraudhttp://www.michigan.gov/fraud

Michigan Medicaid Integrity Program

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