Federal rules require that Medicaid providers take steps to prevent fraud and abuse. This includes:
- Billing Medicaid correctly for services actually provided to recipients
- Advising Medicaid regarding changes in status, such as when a doctor leaves a provider group or clinic
- Ensuring that the care provided to recipients is medically necessary and rendered in a manner that is consistent with current medical practice
- Reporting recipients who "doctor shop" in an effort to obtain prescriptions that can be sold "on the street"
Cases of suspected provider fraud and patient abuse are referred to the Medicaid Fraud Control Unit in the Alabama Attorney General's office. Providers in violation of Medicaid rules and regulations may receive administrative or other sanctions, suspension of payments, limits on participation in the Medicaid program, or termination from the program.
Provider Review / RAC Review Process
- Click here to learn more about this provider audit program to improve payment accuracy by identifying under and overpaymments in Medicaid.
- Self-Audits - Information on notification of intent, self-audit options and required documents
- Provider Education Checklists - Information on denials, reasons for recoupments, where to find information in the Medicaid Provider Billing Manual, free tools and contacts for providers to use - 4/10/14
- CMS Education and Training Resources - Resources from the Centers for Medicare and Medicaid Services (CMS) Center for Program Integrity