C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.18

Current through 2024-51, December 18, 2024

Subsection 144-101-I-1.18 - PROGRAM INTEGRITY

The Program Integrity Unit, Division of Audit, or the Department's Authorized Entity, or any combination of the three (3) entities, is responsible for surveillance and referral activities that may include, but are not limited to:

A. A continuous sampling review of the utilization of care and services for which payment is claimed;

B. An on-going sample evaluation of the necessity, quality, quantity and timeliness of the services provided to members;

C. An extrapolation from a random sampling of claims submitted by a provider and paid by MaineCare;

D. A post-payment review that may consist of member utilization profiles, provider services profiles, claims, all pertinent professional and financial records, and information received from other sources;

E. The implementation of the Restriction Plans (described in Chapter IV of this Manual);

F. Referral to appropriate licensing boards or registries as necessary;

G. Referral to the Maine Attorney General's Office, Healthcare Crimes Unit, for those cases where fraudulent activity is suspected; and

H. A determination whether to suspend payments to a provider based upon a credible allegation of fraud.

The Department and its professional advisors regard the maintenance of adequate clinical and other required financial and product-related records as essential for the delivery of quality care. In addition, providers should be aware that comprehensive records, including but not limited to: treatment/service plans, progress notes, product and/or service order forms, invoices, and documentation of delivery of services and/or products provided are key documents for post-payment reviews. In the absence of proper and comprehensive records, no payment will be made and/or payments previously made may be recouped.

C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.18