It is the mission of the Program Integrity Section to ensure that:

• Medicaid dollars are paid correctly by identifying overpayments to providers of health services and Medicaid recipients occurring due to error, abuse, or fraud.
• Overpayments are recovered and the proper agencies are informed of any potentially fraudulent actions.
• Third party payments available for medical care (insurance, child support, liability settlements, Estate Recovery, etc.) are applied prior to Medicaid payment or recovered after payment.
• Recipients receive quality care and that their rights are protected.
• Problems found are communicated to appropriate staff, providers and recipients and corrected through education and/or changes to the policy, procedure, or process, and monitored for corrective action effectiveness.

We achieve our mission by:

• Conducting post payment reviews of:
• provider billing practices and cost reports
• payment of claims by the fiscal agent
• recipient eligibility determinations
• Identifying overpayments for recovery.
• Identifying medical, administrative, and reimbursement polices or procedures that need to be changed
• Educating providers on errors made
• Assessing the quality of care for Medicaid recipients
• Assuring that Medicaid pays for only medically necessary services
• Overseeing recipient fraud and abuse activities of the county departments of social services to assure that recipient overpayments are recouped
• Ensuring that all available insurance benefits or payments for medical care payable by a third party are applied to claims for services payable by Medicaid
• Identifying and referring suspected Medicaid fraud cases to the Attorney General's Medicaid Investigations Unit, other state agencies, professional boards (e.g. boards of pharmacy, dentistry, etc.) or to federal agencies for investigation (e.g. DEA)

July 11, 2008