Program Integrity (PI) is responsible for monitoring and safeguarding the MaineCare Program against fraud, abuse and waste. It conducts analysis of MaineCare billings to detect utilization patterns or trends that may indicate fraud, abuse or waste. Based on data analysis or referrals/complaints received from other state agencies, health care providers or members, PI may perform retrospective audits/reviews of MaineCare Providers and members to validate the allegations of fraud, abuse or waste.
- Authority: PI's authority to conduct reviews and administer sanctions is described in the MaineCare Benefits Manual (MBM), Chapter 1, § 1, General Administrative Policies and Procedures (word*)
- Audits: The Division's authority to monitor MaineCare payments through audits and post-payment reviews is described in MBM Chapter 1, § 1.16 (word*)
- Utilization Review: MBM Chapter 1, § 1.17 (word*)details the responsibilities for conducting utilization review and the authority to request and receive medical records and other supporting records as needed.
- Surveillance: MBM Chapter 1 § 1.1 (word*)8 lists PI's responsibilities for monitoring the MaineCare Program through continuous sampling of claims which can include extrapolation, and evaluation of necessity and quality of services. It also provides authority to make referrals to licensing boards and registries when appropriate, and to refer cases to the Healthcare Crimes Unit in instances of suspected fraud.
- Grounds for Sanctioning and/or Recouping: MBM Chapter 1 §1.19-1 (word*)lists the grounds from which PI may impose sanctions or request recoupment of funds.
- Sanction Actions, Impositions, Scope and Notification: MBM Chapter 1, § 1.19-2, 1.19-3 and 1.19-4 (word*)describe the type of sanctions that PI may invoke, factors to be considered when imposing a sanction, the scope of the sanctions, and the notification requirements.