The Integrity Division also fulfills the program integrity functions required by the Centers for Medicare and Medicaid Services (CMS) under federal regulations 42 CFR §455.13-17, 42 CFR §455.21-23 and 42 CFR §455.500-518. All states that participate in the federal Medicaid Program are required to maintain a program integrity function to ensure the identification, investigation and referral of suspected fraud and abuse cases.
The Integrity Division conducts investigations into alleged Medicaid fraud, waste and abuse and receives referrals from the public, beneficiaries, providers and other government and/or state law enforcement and regulatory agencies.
Examples of health services provider fraud, waste and abuse:
Billing for medical services not actually performed.
Billing for unnecessary services.
Billing for more expensive services than actually performed.
Billing for services separately that should legitimately be one billing.
Billing more than once for the same medical service.
Dispensing generic drugs but billing for brand-name drugs.
Billing for supplies/medication not dispensed.
Giving or accepting something of value (e.g., cash, gifts, services) in return for medical services and/or patient referrals (i.e., kickbacks).
Contract Oversight Section
Managed Care Oversight: The Integrity Division is responsible for monitoring the program integrity activities of each of Michigan Medicaid’s Managed Care Organizations (MCO). Quarterly, each MCO is required to report the program integrity activities performed. These activities include data mining, audits, investigations, overpayment recoveries, etc.
Recovery Audit Contractors: The Integrity Division has contracted with one vendor to perform audits and recover overpayments from Medicaid providers.
Outreach and Educational Activities
The Integrity Division offers educational presentations regarding Program Integrity in Michigan Medicaid to provider associations, Medicaid staff and other departmental staff.
Data Mining Activities
The Integrity Division uses analytical tools and techniques, coupled with knowledge of Medicaid program rules/regulations, to mine Medicaid claims data and identify improper claim conditions or anomalies.
Medicaid Fraud Referrals
In addition to data mining activities and internal research, the Office of Inspector General’s Integrity Division also relies upon outside referrals as a means of identifying fraud, waste, and abuse within the Medicaid program. Referral sources include, but are not limited to, Medicaid recipients, health plans, and medical providers. Suspected fraud, waste, and abuse can be reported by accessing www.michigan.gov/fraud or by calling 855-MI-FRAUD.