Monitor and audit providers who participate in Wisconsin Medicaid
The Office of Inspector General is responsible for the
prevention and detection of provider fraud, waste and abuse in
Wisconsinís Medicaid program. These responsibilities are carried
out by the Medical and Program Audit Review Sections which are
- Auditing Medicaid providers to ensure compliance with
Medicaid rules and regulations.
- Reviewing, monitoring, and researching provider billing
to detect and identify potential fraud, waste, and abuse.
- Investigating allegations of fraud, waste, and abuse.
- Providing education and technical assistance to the
provider community through the audit activities.
- Recommending new policies, or changes to existing
policies, that promote and protect the Medicaid program.
Strategies to detect and prevent provider fraud and abuse.
- Mandating that providers register to become
- Verification of enrollee information such as social
security number and income
- Educating providers and beneficiaries about Medicaid
rules and regulations
- Requiring that certain services and products be reviewed
through the prior authorization process before payment can
- Ensuring contracts with providers contain language to
help prevent fraud, waste and abuse
- Conducting on-site visits to high-risk providers before
Claims Processing Safeguards:
- Ensuring the claims processing system has appropriate
edits and audits in place to prevent medically unlikely
claims (e.g. age/gender mismatch)
- Ability for manual claims intervention as needed
- Suspending provider payments when credible allegations
of fraud exist
- Issuing Explanation of Benefits to members to assist in
reporting of fraudulent claims
- Providing Remittance Notices to providers for review of
payments for possible errors
- Conducting audits and reviews of providers for
compliance with Medicaid rules and regulations
- Referring suspected cases of fraud, waste and abuse to
law enforcement and assisting in investigations
Office of the Inspector General Outcome
November 25, 2013