The IG MPI Investigations Division conducts investigations of Medicaid providers regarding allegations of Fraud, Waste and Abuse in the Medicaid program. Referrals can come from:
• Medicaid provider complaints.
• Self-Initiated referrals based on information obtained from data queries, sister agencies, provider and community outreach or other external sources.
• Financial audits which determine funds were not used as intended or which identify overpayments and disallowed costs.
MPI Intake Resolution Unit (IRU) receives most Medicaid provider complaints through the Waste, Abuse, Fraud, and Electronic Reporting System (WAFERS known as the external website) or internally (originating from the Integrity Intake (Hotline) or OIG internal staff. …show more content…
However, the complaint will be entered into WAFERS by MPI staff for tracking purposes and processed through the same review as other WAFERS complaints.
Complaints may also come through a Provider-Self Report Protocol. This is when a provider has self-discovered evidence of an overpayment by a health and human services program due to a mistake or potential fraud by a provider may submit a self-investigative report.
Complaints are researched for opening a case and for the priority level based on predetermined criteria. Intake bases priority of case pursuit on the completeness of information initially provided in the complaint. If the complaint involves issues outside OIG’s jurisdiction, MPI forwards the complaint to the appropriate agency or entity if that can be determined. Complaints that cannot be opened or forwarded will have a notation made in WAFERS stating the reason for not pursuing the complaint.
IRU transfer for Full-Scale Investigation
Preliminary Investigations can be recommended for full-scale investigation in any of the following scenarios:
I. An MCO/DMO-SIU investigation is received - reporting systemic discrepancies, or IRU analysis discovers similar billing patterns in other payer's data, i.e. FFS, other MCO/DMO …show more content…
Complaints on providers that have already been educated and have a history of potential fraud, waste or abuse.
IRU transformation (new Fiscal year 2017) for Full-Scale Investigation
New MCO/DMO-SIU consideration and approach - former MCO/DMO SIU referrals had been returned to the original referral source based on MCO/DMO actions associated with recoupment and/or past/former corrective actions (taken by other government entities) which may have taken place regarding a specific provider or entity identified through a respective complaint or allegation. This is no longer the case. For FY 2017 and forward, all investigations referred from an MCO/DMO SIU will be given the full attention required to thoroughly conduct a preliminary investigation in a manner which best supports a timely and thorough investigation.
In addition, the newly formed MPI MCO-SIU Liaison Program will incorporate a new team-approach to collaborating with MCO-SIU’s in terms of monitoring and tracking cases referred by the MCO-SIU’s as well as regularly collaborating on the latest advances in addressing issues of fraud, waste and abuse regarding Medicaid. This includes the identification of new trends, schemes, and activities which are identified as conducive to fraud, waste, and
• Medicaid provider complaints.
• Self-Initiated referrals based on information obtained from data queries, sister agencies, provider and community outreach or other external sources.
• Financial audits which determine funds were not used as intended or which identify overpayments and disallowed costs.
MPI Intake Resolution Unit (IRU) receives most Medicaid provider complaints through the Waste, Abuse, Fraud, and Electronic Reporting System (WAFERS known as the external website) or internally (originating from the Integrity Intake (Hotline) or OIG internal staff. …show more content…
However, the complaint will be entered into WAFERS by MPI staff for tracking purposes and processed through the same review as other WAFERS complaints.
Complaints may also come through a Provider-Self Report Protocol. This is when a provider has self-discovered evidence of an overpayment by a health and human services program due to a mistake or potential fraud by a provider may submit a self-investigative report.
Complaints are researched for opening a case and for the priority level based on predetermined criteria. Intake bases priority of case pursuit on the completeness of information initially provided in the complaint. If the complaint involves issues outside OIG’s jurisdiction, MPI forwards the complaint to the appropriate agency or entity if that can be determined. Complaints that cannot be opened or forwarded will have a notation made in WAFERS stating the reason for not pursuing the complaint.
IRU transfer for Full-Scale Investigation
Preliminary Investigations can be recommended for full-scale investigation in any of the following scenarios:
I. An MCO/DMO-SIU investigation is received - reporting systemic discrepancies, or IRU analysis discovers similar billing patterns in other payer's data, i.e. FFS, other MCO/DMO …show more content…
Complaints on providers that have already been educated and have a history of potential fraud, waste or abuse.
IRU transformation (new Fiscal year 2017) for Full-Scale Investigation
New MCO/DMO-SIU consideration and approach - former MCO/DMO SIU referrals had been returned to the original referral source based on MCO/DMO actions associated with recoupment and/or past/former corrective actions (taken by other government entities) which may have taken place regarding a specific provider or entity identified through a respective complaint or allegation. This is no longer the case. For FY 2017 and forward, all investigations referred from an MCO/DMO SIU will be given the full attention required to thoroughly conduct a preliminary investigation in a manner which best supports a timely and thorough investigation.
In addition, the newly formed MPI MCO-SIU Liaison Program will incorporate a new team-approach to collaborating with MCO-SIU’s in terms of monitoring and tracking cases referred by the MCO-SIU’s as well as regularly collaborating on the latest advances in addressing issues of fraud, waste and abuse regarding Medicaid. This includes the identification of new trends, schemes, and activities which are identified as conducive to fraud, waste, and