Program Integrity

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

Examples:

• Billing for services not rendered
• Billing for more costly services than rendered (upcoding)
• Falsifying medical or billing records to obtain greater reimbursement (i.e., medically necessary documentation, prior authorization requests)
• 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 product

Any action that results in an incorrect payment for services rendered or involving patterns of overutilization or misutilization of services without demonstrated intent or false statements.

Examples:

• 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

• Criminal investigation and/or prosecution
• Civil monetary penalty
• Exclusion from OIG, Medicare and/or Medicaid permanently or for a period of time
• Referral to professional licensing board
• Restitution of Medicaid overpayment
• Peer review
• Education
• Other administrative remedies