Iowa Medicaid Program Integrity

The responsibilities of the Program Integrity team include: 

• Enforcement of Federal and State Rules and Regulations
• Governance of Federal and State Rules and Regulations
• Exclusions and Sanctions
• Program Integrity Oversight of Managed Care Plans
  • Medical Managed Care
  • Dental Managed Care
• Audits and Investigations pertaining to Fraud, Waste and Abuse
• Payment Error Rate Measurement (PERM) Audits
• Overpayment Recoveries
• Program Integrity Fiscal Management
• Program Integrity Data Analytics

Gov. Reynolds signs Executive Order 20 establishing Medicaid Fraud Elimination Task Force 

Fraud

Fraud is the intentional and criminal misuse of Medicaid funds.

Examples of Medicaid fraud are: 

• Billing Iowa Medicaid for services that were never provided.
• Using another person's Medicaid card to obtain services.
• Falsifying medicais records to receive payment.
• Billing for a more expensive service than was actually provided ("upcoding").
• Paying or receiving kickbacks for Medicaid referrals.

Waste

Waste involves practices that lead to unnecessary costs to the Medicaid program, typically due to overuse or misuse of services or resources

• Ordering unnecessary medical tests or procedures.
• Scheduling more frequent visits than medically necessary.
• Prescribing medications without considering lower-cost, equally effective alternatives.
• Poor administrative processes that result in duplicate payments.
• Excessive use of emergency departments for non-emergency conditions when appropriate alternatives are available.

Abuse

Abuse is behavior that is inconsistent with accepted medical, business, or fiscal practices and results in unnecessary costs or payments. 

Abuse may not involve intentional deception but can still violate Medicaid policies or program requirements.

• Billing incorrectly due to repeated disregard of Medicaid billing rules.
• Failing to maintain required documentation for services billed.
• Charging Medicaid for services that were not medically necessary.
• Repeatedly submitting claims with coding errors that increase reimbursement.
• Providing services that do not meet Medicaid coverage requirements.

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

Iowa Medicaid Authority (87.2 KB) .pdf

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.

CMS Program Integrity Reviews

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 FY17 Focused PI Review Final Report (276.67 KB) .pdf

Iowa FY21 PI Review Final Report (623.92 KB) .pdf

Electronic Visit Verification

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 Sanctions List (137.69 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]