PROGRAM INTEGRITY

MISSION STATEMENT

The mission of the Office of Medicaid Policy and Planning (OMPP) Program Integrity Unit is to guard against fraud, abuse, and waste of Medicaid program benefits and resources.

CONTACT INFORMATION

Member and Provider Concerns line: 1-800-457-4515

Program Integrity email: program.integrity@fssa.in.gov

FREQUENTLY ASKED QUESTIONS

Q. What is provider fraud?

A. Misrepresentation with the intent to illegally obtain services, payments, or other gains.

Examples include, but are not limited to:

  • Billing for services not rendered
  • Billing for more costly services than rendered (upcoding)
  • Billing more than the charge to the general public
  • Billing for services provided by unqualified or unlicensed personnel
  • Receiving kickbacks from medical providers for referrals or use of a product

Q. What is provider abuse?

A. Any action that is inconsistent with generally accepted practices (both clinically and from a business standpoint) which results in an incorrect payment for services rendered.

Examples include, but are not limited to:

  • Rendering or ordering excessive services, especially diagnostic tests
  • Providing services inconsistent with the diagnosis and treatment of the recipient
  • Rendering or ordering medically unnecessary services
  • Poor or unsatisfactory quality of care provided to a recipient
  • Billing recipient for remaining balance after Medicaid payment

Q. What are the potential consequences to the provider for fraudulent or abusive activities?

A. Potential consequences to the provider depend on the intent demonstrated and the severity of the activity.

Examples include, but are not limited to:

  • Criminal investigation and/or prosecution
  • Civil monetary penalties
  • Exclusion by the Office of the Inspector General from Medicare and/or Medicaid, permanently or for a period of time
  • Referral to the Indiana Professional Licensing Agency
  • Pre-payment review
  • Payment suspension
  • Recoupment of Medicaid overpayment
  • Other administrative remedies