The Medicaid Program Integrity Division (MPI) investigates and reviews allegations of fraud, waste, and abuse committed by Medicaid providers, who may be subject to a range of administrative enforcement actions including education, prepayment review of claims, penalties, required repayment of Medicaid overpayments, and/or exclusion from the Medicaid program. Some referrals come through the OIG fraud hotline or complaints from the Inspector General’s online Waste, Abuse and Fraud Electronic Referral System. Referrals are also received from managed care organizations (MCOs) throughout the state.

MPI makes referrals to the Attorney General's Medicaid Fraud Control Unit (AG-MFCU) when there are indicators of criminal Medicaid fraud. MPI and AG-MFCU work together on joint investigations by sharing resources and information that will lead to successful administrative or criminal prosecution.

Medical Reviews

The Medical Reviews unit conducts claims and medical record reviews on a variety of health and human services, including acute care utilization, hospital utilization, nursing facility utilization, research and detection, and pharmacy lock-in. The division also provides clinical consultation to the Benefits Program Integrity, Audit, and Inspections and Investigations divisions on dental, medical, nursing, and pharmacy services.

Medical Reviews is comprised of:

The Clinical Subject Matter Expert (CSME) team includes a physician, dentist, dental hygienist, and pharmacist who provide clinical expertise to Inspector General investigations, audits, inspections, special collaborative initiatives, and OIG legal staff. The CSME team also communicates with Managed Care Organization (MCO) and Dental Management Organization (DMO) compliance departments to educate and to clarify questions regarding clinical documentation and medical/dental policy interpretation.

The Acute Care Surveillance (ACS) team identifies patterns of aberrant billing, performs Surveillance Utilization Reviews required by the federal Centers for Medicare and Medicaid Services, develops and runs targeted data queries to identify acute care billing outliers, and collects Medicaid overpayments.

The Quality Review team conducts retrospective utilization review of hospitals and nursing facilities, and administers the pharmacy Lock-In Program. The Utilization Review team performs onsite and desk reviews of hospital claims and nursing facility Minimum Data Set forms for appropriate billing. Lock-In Program staff work with managed care organizations to monitor recipient use of prescription medications and acute care services.

NFUR stakeholder information

Hospital stakeholder information