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Program Integrity
Program Integrity is the work Iowa Medicaid does to make sure Medicaid dollars are used correctly. Our job is to prevent problems, find issues early, and take action when needed.
We help protect the program so members can rely on their services, providers can trust the system, and taxpayer dollars are spent appropriately.
List items for PI Mission
The Program Integrity and Compliance Bureau:
Reviews all reports of potential fraud, waste, or abuse
Monitors claims and billing patterns
Uses data tools to spot suspicious activity
Conducts audits and targeted reviews
Checks provider eligibility and exclusion lists
Works closely with managed care organizations
Refers credible cases to the Medicaid Fraud Control Unit (MFCU) for investigation
Most issues we find are mistakes or misunderstandings. Some require deeper review. If something appears serious and credible, it is sent to the MFCU for law‑enforcement‑level investigation.
Fraud
Fraud is intentionally misusing Medicaid funds. Examples include billing for services not provided, using someone else’s Medicaid ID, or upcoding services.
Waste
Waste happens when actions lead to unnecessary costs, often due to inefficient practices or overuse, like scheduling services more frequently than medically needed.
Abuse
Abuse includes actions that go against accepted medical or billing practices and cause unnecessary costs. Abuse may not be intentional but still violates Medicaid rules.
To keep Medicaid running properly, Iowa uses several safeguards:
Provider screening and monthly exclusion checks
Routine and targeted audits
Data analytics to identify unusual billing
Close oversight of managed care plans
Collaboration with state and federal partners (HHS‑OIG, MFCU, and SAM exclusion systems)
These tools help us detect problems early and prevent improper payments before they happen.
Program Integrity keeps Medicaid strong. When issues are found early and handled properly, funds can continue supporting the Iowans who rely on this program every day. Our team works to ensure Medicaid stays fair, accountable, and focused on the people it serves.
Explore the Data
Iowa Medicaid shares annual trends from Program Integrity activities, including:
Audits completed
Cases reviewed
Cases referred to MFCU
Dollars recovered
Program observations and trends
By sharing this information, Iowa shows how oversight protects the program and adapts to changes over time.
Resources and Training
List items for Program Integrity Resource Library
The Program Integrity (PI) Audits and Investigations Unit performs reviews of claims paid by Iowa Medicaid to ensure services were billed and paid appropriately. Reviews can originate from external or internal sources, with the majority initiated by internal data studies.
The review process includes a series of letters with instructions to providers regarding needed actions and next steps. It is very important for providers to have a correct/current address for correspondence in their provider enrollment file. Failure to follow up on required actions outlined in the letters may result in sanction actions by Iowa Medicaid, which can include suspension of payments and participation with the Medicaid Program. The most common letters in the review process are:
- MRR (Medical Records Request) letter – Includes a list of members and the timeframes related to the claims under review. The letter allows providers 30 days from the date of the letter to respond. Written requests for time extensions will be considered, with reason. Records must be maintained by providers and submitted for review requests according to IAC 441—79.3(249A) Maintenance of records by providers of service.
- PROTO (Preliminary Report of Tentative Overpayments) letter – Informs providers of potential overpayments identified in the review. Providers have 15 days from date of letter to submit a written request for a re-evaluation, with 15 more days to submit additional documentation.
- FOR (Finding and Order for Recoupment) letter – Informs providers of final review decisions. Identified overpayments must be paid within 30 days of the date of the letter or additional collection action and sanctions may be enforced. Outstanding overpayments will result in mandatory suspension from participation with the IA Medicaid Program as outlined in IAC 441 79.2(3)(c)(3). Providers have 90 days from the date of the findings letter to request an appeal.
To avoid unnecessary sanctions, providers should read letters in their entirety and follow included instructions. The PI Audits & Investigations Unit will work with providers throughout the review process to help ensure any needed actions are resolved. Providers may contact PI Audits and Investigations using one of the methods below, or by calling the individual reviewer’s phone number included in the letter:
- Email: [email protected]
- Toll Free: 1-877-446-3787
Center for Program Integrity (CPI) ensures CMS is paying the correct provider the correct amount for services covered under CMS programs. CPI works with states, providers, and stakeholders to ensure accurate billing and provider enrollment.
CPI’s mission is to detect and combat fraud, waste, and abuse of the Medicare and Medicaid programs. For more information, please visit https://www.cms.gov/About-CMS/Components/CPI.
Centers for Medicare and Medicaid Services (CMS) conducts comprehensive reviews of each state’s Medicaid Program Integrity (PI) activities. The comprehensive reviews involved an in-depth assessment of the state’s PI activities which include regulatory compliance, surveillance and utilization systems, case tracking, pre and post payment reviews, provider enrollment and disclosures, interactions with the state’s Medicaid Fraud Control Units (MFCU), and oversight of managed care operations. In 2014, CMS began conducting focused reviews to determine the extent of PI oversight of Medicaid program. CMS publishes the reviews by state on the State Program Integrity Reviews webpage at www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/StateProgramIntegrityReviews.
Iowa’s published reviews:
Iowa FY10 Comprehensive PI Review Final Report (121.77 KB) .pdf
Iowa FY13 PI Comprehensive Review Final Report (197.96 KB) .pdf
Iowa Law and Rules | https://www.legis.iowa.gov/lawhttps://www.legis.iowa.gov/law
Iowa Code | Title VI – Human Services (Ch. 216 – 255A) | Chapter 249A | https://www.legis.iowa.gov/law/statutory
Iowa Administrative Code | Human Services Department (441) | Chapters 46, 73, 76, 79 |
https://www.legis.iowa.gov/law/administrativeRules/agencies
Program Integrity | 42 CFR Part 455 | https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-455?toc=1
View Iowa Medicaid Sanction List (142.29 KB) .xlsx
- A list of providers that are found to be in violation of the Iowa Medicaid Program.
- The list identifies all individuals, organizations, and entities that Iowa Medicaid Program Integrity Unit has taken an adverse action against for the following reasons:
- Involuntarily Terminated from Participation
- Involuntarily Suspended from Participation
- OIG Excluded
- Medicare Revocations
- Outstanding Overpayments
- Sanction list verifications should be sent to [email protected]
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