The Missouri Department of Social Services runs the State of Missouri Medicaid program. Medical providers who are eligible participants in Missouri’s Medicaid program are subject to specific rules and regulations.

The voluminous amount of rules and regulations often leave medical providers confused and unable to keep up with the mandatory requirements. As a result, medical providers may become subject to a potential investigation by the Missouri Medicaid Audit & Compliance Unit.

The Initial Investigation

The Missouri Medicaid Audit and Compliance Unit (MMAC) are constantly reviewing eligible providers. The MMAC investigates allegations of fraud, waste and abuse by providers. The investigation occurs by either an on-site review or a desk review.

On-Site Review – This investigation occurs at the medical provider’s office. The MMAC will review all relevant documents, including medical records, invoices, appointment calendars, sign in sheets, signature logs, timesheets, invoices, physician orders, certificates of medical necessity, plan of care, progress notes, travel logs, and trip tickets. In addition, the MMAC will interview employees and examine the billing practices of the medical provider.

Desk Review – This investigation occurs at the MMAC’s office. The MMAC will send a request to the medical provider to provide all relevant documents.

Allegation of Fraud

If the MMAC’s investigation uncovers a reliable allegation of fraud by a medical provider, then the MMAC will forward the information to the Medicaid Fraud Control Unit (MFCU) and the Division of Legal Services Unit for review.

The Missouri Attorney General’s Office defines Medicaid provider fraud as the misrepresentation of the services rendered and thereby increases the reimbursement from Missouri Medicaid.

Examples of Medicaid provider fraud provided by the Missouri Attorney General’s Office include:

  • Billing for any services not actually performed, known as “phantom billing;”
  • Billing for a more expensive service than was actually rendered, known as “upcoding;”
  • Billing for several services that should be combined into one billing, known as “unbundling;”
  • Billing twice for the same medical service;
  • Dispensing generic drugs and billing for brand-name drugs;
  • Giving or accepting something in return for medical services, known as a “kickback;”
  • Bribery;
  • Billing for unnecessary services;
  • Submitting false cost reports; and
  • Falsifying timesheets or signatures in connection with the provision of personal care or consumer directed home health services.

Potential Sanctions

Medical providers may be subject to certain sanctions, including but not limited to:

  • Education
  • Overpayment
  • Payment Review
  • Payment Suspension
  • Suspension
  • Termination

Legal Help

If you are a medical provider subject to an investigation by the Missouri Medicaid Program and facing potential legal consequences, you should contact an attorney immediately.  An attorney can help assist and protect the medical provider’s rights during the investigation process. Medical providers are allocated certain rights such as a temporary suspension of sanctions hearing as well as a formal administrative hearing at the end of the investigation.

Missouri medical providers should know their rights. Never allow the voluminous amount of Medicaid rules and regulations to leave your company confused and subject to potential sanctions.

Written by Attorney Greg Klote

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