CurrentAlabama MedicaidPolicy N/A
Program Integrity (Chapter 4) — Alabama Medicaid
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Establishes the Program Integrity Division responsibilities, definitions, methods, and sanctions to detect, prevent, and address fraud, waste, and abuse by providers and recipients in the Alabama Medicaid program. Applies to Alabama Medicaid operations, enrolled providers, recipients, and Program Integrity staff.
Policy Summary
PayerAlabama Medicaid
PolicyProgram Integrity (Chapter 4) — Alabama Medicaid
Policy CodePolicy N/A
Change TypeMinor / no material changes
Effective DateJul 15, 2023
Last ReviewJul 15, 2023
Next Review DateN/A
Key ActionProviders must provide records free of charge to investigators and designated representatives during reviews or investigations.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
6rules in Chapter 4
6 sub-itemsprimary purposes
rangeprovider sanctions
1 yrrecipient sanction min
3 yrsPERM frequency
Program Integrity Operational Criteria
Program Integrity operational criteria
Operational criteria, processes, and remedies the Program Integrity Division uses to detect, investigate, and respond to suspected fraud, waste, or abuse.
Program Integrity Division responsibilities: plan, develop, and direct efforts to identify, prevent, and prosecute fraud, waste, and/or abuse; verify services are appropriate and rendered as billed; confirm services are provided by qualified providers to eligible recipients; ensure payments are correct and pursue all identified funds for collection.
Detection methods: acquire, organize, and analyze data; generate special computer reports to develop statistical profiles of health care delivery and utilization patterns; reveal suspected instances of potential fraud, waste, and/or abuse by practitioners, providers, recipients, or sponsors; and identify potential deficiencies in level or quality of care or State resolution procedures.
Reviews and investigations: conduct in-house and on-site reviews and investigations; staff shall properly identify themselves to providers or recipients; request pertinent information directly from the provider, administrator, or designated person; prepare and present findings for prosecution, corrective action, and/or sanction.
Referrals: suspected recipient fraud cases are referred to local law enforcement for prosecution upon completion of investigation; credible allegations of provider fraud and nursing home patient account abuse are, after preliminary investigation, referred to the Medicaid Fraud Control Unit for full investigation and possible prosecution.
Provider cooperation requirement: providers participating in Alabama Medicaid must make available, free of charge, necessary records and information to Medicaid investigators, the Attorney General's staff, or other designated Medicaid representatives during reviews or investigations.
Possible administrative and corrective actions
- For providers: warning letters, suspension of payments, prepayment review, restrictions, exclusion, termination, and pursuit of restitution as appropriate.
- For recipients: warning letters, restriction to one provider or pharmacy, suspension of benefits, and ineligibility periods (minimums: 1 year for first fraud determination; 2 years for second; 4 years for recurring occurrences) until restitution is made as required by Code of Alabama Section 22-6-8.
Due process and notice: at least ten days prior to imposing administrative sanctions for fraud, waste, or abuse, the recipient (and for certain provider sanctions) shall be provided with a notice of violation setting forth reasons and the right to an administrative hearing.
Considerations in sanctioning: factors include seriousness and extent of violations, history of violations and prior sanctions, willingness to comply, any peer review or licensing actions, and impact on local health care delivery; affiliates may be sanctioned on a case-by-case basis with regard to relevant facts.
Effect of exclusion: payments are prohibited for services furnished by excluded providers on or after the effective exclusion date; organizations may not submit claims for excluded individuals after the exclusion effective date.
Recipient-specific operational rules: Program Integrity reviews suspected recipient fraud/waste/abuse using system and medical data and interviews as needed; marginal abuse may result in a warning letter; recipients suspended for fraud who reapply during pregnancy may be changed to a restricted status for pregnancy-related services during pregnancy and up to 12 months postpartum; restricted recipients have utilization reviewed at least annually and have rights to reconsideration and fair hearing; loss of eligibility while restricted results in remaining restricted upon reinstatement pending medical staff review.
Quality control and measurement: the Eligibility Quality Control unit selects monthly random samples to review eligibility determination errors and participates in Payment Error Rate Measurement (PERM) eligibility reviews once every three years; findings inform corrective actions to reduce erroneous Medicaid payments.
Sanctions, Legal References, and Recipient Durations
Sanctions and legal referencesmixed
| No codes listed |
Recipient ineligibility durations — sanctions for fraud
First fraud determinationMinimum ineligibility period of 1 year and until full restitution is made to the State of Alabama
Second fraud determinationMinimum ineligibility period of 2 years
Recurring fraud determinationsMinimum ineligibility period of 4 years for recurring occurrences
Provider Cooperation and Administrative Sanctions
Denial Risk
Exclusion, termination, and affiliate sanctions
Medicaid will initiate exclusion or termination proceedings for providers convicted of Medicaid fraud or related crimes, excluded from Medicare for fraud/abuse, or suspended/terminated by a licensing authority; affiliates may also be sanctioned on a case‑by‑case basis.
- Initiate proceedings to exclude or terminate providers convicted of defrauding Medicaid or convicted of crimes related to delivery of medical care (10(10)(a)).
- Initiate proceedings for providers excluded/terminated from Medicare for fraud/abuse (10(10)(b)).
- Initiate proceedings for providers suspended or terminated by professional licensing authorities (10(10)(c)).
- Apply sanctions to known affiliates after case‑by‑case consideration (10(11)).
Key Definitions
Fraud — definition and notes
DefinitionIntentional deception or intentional misrepresentation made by a person with the knowledge that the deception could result in some unauthorized personal benefit or unauthorized benefit to some other person; requires evidence substantiating misrepresentation with intent to illegally obtain services, payment, or other gains.
Intent requirementFraud is dependent upon evidence that must substantiate misrepresentation with intent to illegally obtain services, payment, or other gains.
Criminal consequencesCode of Alabama (1975) Section 22-1-11 makes falsifying a claim or application for Medicaid benefits, or offer/pay/receive kickbacks, a felony punishable by fines up to $10,000 or imprisonment one to five years per violation.
Program abuse — definition and examples
DefinitionProgram abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in unnecessary cost to the Medicaid program, or in reimbursement for services which are not medically necessary or that fail to meet professionally recognized standards for health care.
Scope limitationFindings by the state survey agency of non‑compliance by a nursing facility with conditions of participation are not considered program abuse under this definition; remedies for those noncompliances are governed elsewhere (Rule 560‑X‑10‑.27).
ExamplesIncludes over‑utilization by furnishing or prescribing services or merchandise that are not medically necessary, not requested by the recipient, or not generally provided to private‑pay patients.
Policy Summary
PayerAlabama Medicaid
PolicyProgram Integrity (Chapter 4) — Alabama Medicaid
Policy CodePolicy N/A
Change TypeMinor / no material changes
Effective DateJul 15, 2023
Last ReviewJul 15, 2023
Next Review DateN/A
Key ActionProviders must provide records free of charge to investigators and designated representatives during reviews or investigations.
SourceLink
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