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: programintegrity@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