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 Wisconsin’s Medicaid program. These responsibilities are carried out by the Medical and Program Audit Review Sections which are responsible for:

  • 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.

Prepayment Safeguards:

  • Mandating that providers register to become Medicaid-certified providers
  • 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 be made
  • Ensuring contracts with providers contain language to help prevent fraud, waste and abuse
  • Conducting on-site visits to high-risk providers before becoming certified

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

Post-Payment Safeguards:

  • 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 Measures

Last Revised: November 14, 2014