Medicaid Program Integrity

What is Medicaid Program Integrity?

Medicaid Program Integrity is a system of reasonable and consistent oversight of the Medicaid program. Program Integrity effectively:

• encourages compliance
• maintains accountability
• protects public funds
• supports awareness and responsibility
• ensures that providers meet participation requirements
• ensures that services are medically necessary
• ensures payments are for the correct amount and for covered services

The goal of Program Integrity is to reduce and eliminate fraud, waste, and abuse in the Medicaid Program.

Common functions of Program Integrity include prevention, investigation, education, audit, recovery of improper payments, and cooperation with Medicaid Fraud Control Units (MFCU).

Provider Self-Audits

In accordance with 7 AAC 160.115, providers are required to conduct a self-audit every two years. The next round of self-audits should cover either calendar year 2021 or 2022 and are due no later than December 31, 2024.

Effective June 7, 2018, the Department of Health requires all Medicaid providers to conduct a self-audit once every two years, draft a report of the self-audit, sign and submit the self audit attestation form, and to repay all identified overpayments. See Alaska Statute 47.05.235 and Alaska Administrative Code 7 AAC 160.115. Provider Self-Audits.

Contemporaneous Documentation Requirements

The Department had defined contemporaneous record keeping in 7 AAC 105.230(d)(7) on June 7, 2018 to 72 hours from the date of service. Effective February 6, 2020, the Department updated the contemporaneous record keeping in 7 AAC 105.230(d)(7) to 14 days from the date of service. Please see the Frequently Asked Questions (FAQ) created regarding Contemporaneous Documentation Requirements.

Contemporaneous Documentation Requirements

Audits

For an overview of audits and reviews that affect providers who work with the Department of Health visit Care Provider Audits.

What is Fraud and Abuse?

Fraud is defined by:

The Code of Federal Regulations (42 CFR 455.2) as

An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other persons.  It includes any act that constitutes fraud under applicable Federal or State law.

Alaska Statute (AS 47.05.210) as

The crime of medical assistance fraud if the person knowingly submits or authorizes the submission of a claim to a medical assistance agency for property, services, or a benefit with reckless disregard that the claimant is not entitled to the property, services, or benefit;

Abuse is defined by the Code of Federal Regulations (42 CFR 455.2) as

Provider practices that are inconsistent with sound fiscal, business, or medical, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care.  It also includes recipient practices that result in unnecessary cost to the Medicaid program.

Reporting Medicaid Provider Fraud

If you wish to report potential fraud by a provider, call the Medicaid Fraud Control Unit (MFCU) at 907.269.6279.

For more information visit MFCU.

Alaska Excluded Provider List

An excluded provider is one that has been formally sanctioned with termination by the State and/or Federal government. Any provider convicted of medical assistance fraud will be excluded from participating in the Medicaid program.

The Alaska Department of Health Program Integrity Unit maintains a list of providers whose Medicaid provider agreements have been terminated due to sanction or conviction of fraud. This list will be updated as needed; when an individual or entity is either added or removed. Any provider participating or applying to participate in the Medicaid program or hiring staff should review the excluded provider list and the LEIE on a routine basis to determine if an existing or potential employee or contractor has been excluded from participation in the Medicaid program.

For the current Alaska Excluded Provider List visit: Alaska Excluded Provider List

Applying for Reinstatement

Reinstatement of excluded providers is not automatic once the specified period of exclusion ends.  Those wishing to again participate in the Medicaid program must apply for reinstatement and receive notice from Medicaid Program Integrity the reinstatement has been granted.

To apply for reinstatement, send a written request to Medicaid Program Integrity at the address below.  The written request must clear and convincing evidence that the applicant possesses all required licenses and certificates and is qualified to participate. 

If the reason for your original exclusion was a conviction for medical assistance fraud, or misconduct involving a controlled substance, the commissioner of the department may exclude an individual or entity for a period of up to 10 years after unconditional discharge on a conviction. In accordance with Alaska Statue 47.05.240, an individual or entity may not participate in the Medical Assistance program until the applicant establishes to the commissioner by clear and convincing evidence that the applicant possess all required licenses and certificates and is qualified to participate.  For reinstatements following a conviction for medical assistance fraud or misconduct involving a controlled substance, please send your request to: 

LEIE

The U.S. Department of Health & Human Services’ Office of Inspector General (OIG) also maintains a List of Excluded Individuals/Entities (LEIE) containing the names of those who are excluded from participation in federal and state health care programs.  If an individual is on the LEIE, they are not allowed to receive reimbursement for Medicaid services in any capacity, even if they are not on the Alaska Excluded Provider List.

For more information visit the LEIE.