The Medical and Program Audit Review Sections focus on preventing, detecting, and investigating provider fraud, waste, and abuse in Wisconsin’s Medicaid program. Staffers:
- Audit providers to ensure compliance with Medicaid rules and regulations.
- Investigate allegations of fraud, waste, and abuse.
- Provide education and technical assistance to providers through audit activities.
- Recommend new policies, or policy changes, that protect and promote Wisconsin Medicaid.
- Review, track, and research provider billing.
We detect and prevent fraud and abuse throughout the provider payment process.
- Conduct on-site visits to high-risk providers before Medicaid certification.
- Educate providers and beneficiaries about Medicaid rules and regulations.
- Ensure contracts with providers contain language that helps prevent fraud, waste, and abuse.
- Mandate that providers register to become Medicaid-certified.
During Claims Processing:
- Ensure the claims processing system has edits and audits in place to prevent medically unlikely claims (e.g. age/gender mismatch).
- Intervene manually as needed.
- Suspend provider payments when there are credible allegations of fraud.
- Conduct audits and reviews of providers for compliance with Medicaid rules and regulations.
- Issue Explanation of Benefits to members to assist in reporting of fraudulent claims.
- Provide Remittance Notices to providers for review of payments for possible errors.
- Refer suspected cases of fraud, waste and abuse to law enforcement, and assist in investigations.