Program Integrity (PI) is responsible for monitoring and safeguarding the MaineCare program against fraud, abuse and waste through an audit process, driven by referrals from other state agencies, health care providers, and members as well as MaineCare billing analysis to detect utilization patterns or trends.
Maine DHHS Policy Guidance
Program Integrity conducts on-going audits/reviews of all MaineCare providers and their claims for services. PI reviews generally consist of claims data information and the clinical/professional/financial record supporting the services or products that were billed to, and paid for by the MaineCare Program. The focus of the reviews is to ensure that billings are in compliance with all MaineCare rules and regulations and to detect and deter areas of fraud, abuse, and waste.
Examples of fraud, abuse, and waste include, but are not limited to:
- Billing for services not provided;
- Billing for medically unnecessary services;
- Billing for non-covered services disguised as a covered service;
- Pre-billing services;
- Listing phantom employees on budgets used for rate setting;
- Poor or no documentation to support the services billed.
Program Integrity (PI) administers the Department of Health and Human Services' (DHHS) MaineCare Exclusion Program. Excluded individuals or entities are prohibited from enrolling as MaineCare providers or servicing providers. In addition, MaineCare providers are prohibited from employing, directly or indirectly, excluded individuals or entities. Federal regulations prohibit payment for any item or service furnished, ordered, or prescribed by an excluded individual.
Electronic Code of Federal Regulations
Screening for Excluded Individuals of Entities
Providers are required under the MaineCare Provider/Supplier Agreement and the MaineCare Benefits Manual Chapter I, § 1.03-8Y to ensure that "excluded individuals or entities are not employed or utilized to provide services, receive payments, or submit claims, to the MaineCare Program."
We strongly recommend that you screen all your employees and contractors for exclusions. You should screen all new potential employees prior to hire and routinely screen all staff at set time intervals, i.e. annually, quarterly, etc. We also recommend that you require your contractors to screen their staff for excluded individuals. You should check both the state and federal websites. Someone may not be excluded by the federal government and Maine. See the Exclusion Databases (PDF) for details about how to search for excluded individuals.
There are consequences for a provider who employs or contracts with an excluded individual or entity, including reimbursement for paid services. For details, see the Effects of Employing or Contracting with Excluded Individuals or Entities (PDF).
Please immediately report any exclusion violations to Program Integrity.
- Program Integrity
- 11 State House Station
- Augusta, ME 04333-0011
- (207) 287-4660