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Program Integrity

Mission Statement

The mission of the Indiana Office of Medicaid Policy and Planning (OMPP) Program Integrity staff is to guard against fraud, abuse, and waste of Medicaid program benefits and resources.

See the following pages for information about Program Integrity functions:

Contact Information

Indiana Health Coverage Programs (IHCP) Provider and Member Concerns Line: 1-800-457-4515

Program Integrity email: Program.Integrity@fssa.in.gov

Frequently Asked Questions

  • What is provider fraud?

    Provider fraud refers to deception or 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 those that were rendered (upcoding)
    • Billing for a covered service instead of the noncovered service that was actually provided
    • Billing more than the charge to the general public
    • Billing for services provided by unqualified or unlicensed personnel
    • Soliciting, offering, or receiving kickbacks, bribes, or rebates from medical providers for referrals or use of a product
    • Altering a member’s medical records to generate fraudulent payments
  • What is provider abuse?

    Provider abuse is any action by a provider that is inconsistent with generally accepted practices (both clinically and from a business standpoint) and that results 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 healthcare.

    Examples include, but are not limited to:

    • Rendering or ordering excessive services, especially diagnostic tests
    • Submitting claims for services inconsistent with the diagnosis and treatment of the member
    • Rendering or ordering medically unnecessary services
    • Poor or unsatisfactory quality of care provided to a member
    • Billing the member for remaining balance after Medicaid payment
    • Violating any of the provisions of the provider agreement
  • What are the potential consequences to the provider for fraudulent or abusive activities?

    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
    • Prepayment review
    • Payment suspension
    • Recoupment of Medicaid overpayment
    • Other administrative remedies

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