What We Watch For​

• Fraud: This happens when someone purposely gives false information to get money or services they should not get. This is a crime. We work with the police to stop it.
  
• Waste: This is when someone spends money unnecessarily. An example is when a patient gets the same medical test twice because the provider lost the first result.
  

• ​Abuse: This is when a provider or member does something that goes against the rules, but it might not be on purpose. For example, a doctor might bill for a service that was not medically necessary.​
  

Our Commitment

We partner with state and federal partners to monitor for fraud, waste, and abuse and find new risks. The tricks bad actors use change all the time. We update our tools constantly to stay one step ahead.

How You Can Help 

If you suspect Medicaid fraud, waste or abuse, report it. You do not have to give your name.

• Call the Office of Inspector General (OIG) Hotline: 866-770-7175
• Submit the online form: Report Fraud

The Maryland Department of Health (MDH) Office of the Inspector General handles all reports sent to the hotline or online form.

How We Stop Fraud: Our Tools

The Tools We Use to Protect Your Tax Dollars

Maryland uses many high-tech tools and rules to stop fraud before it starts. Here is how we protect the Maryland Medicaid program.

Checking Our Providers 

Before a doctor or facility can join Maryland Medicaid, we check them thoroughly. We use federal databases to make sure they have the right licenses. We also check to see if other health programs have banned them.

Checking Medical Services

Maryland Medicaid has rules to make sure every treatment or doctor's visit is truly necessary. We call this quality care oversight. 

• Getting a Thumbs Up First: For some services, your doctor must ask us for permission before they treat you. This is known as prior authorization. It proves the care fits your medical needs.
• Setting Limits: We have rules on how often you can get certain tests or prescriptions. This prevents people from getting more than is safe or helpful.
• Following the Best Science: We only pay for care that matches the latest medical standards. We give doctors clear guides, so they know exactly what the rules are before they send us a bill.

Electronic Checks 

• Electronic Visit Verification (EVV): For home health care, we use EVV. This is a digital check-in. It proves that the caregiver went to the person’s home and provided the care they billed for.
  
• Medicaid Management Information Systems (MMIS): We use MMIS to check every doctor’s bill before we pay it. This system catches errors, like a bill for two appendix removals on the same person or the wrong combination of medical codes. These automated system checks stop the state from paying for mistakes or services that do not follow our health rules.
  
• Public Assistance Reporting Information System (PARIS): We check PARIS to see whether an individual is receiving Medicaid in another state. This helps prevent duplicate enrollment.
  

Audits and Investigations

State and federal agencies audit Maryland Medicaid to ensure the program follows all laws and uses funds properly.

• The Office of Legislative Audits (OLA): View OLA audit reports.
• The MDH Office of the Inspector General: The Audit Division regularly checks our records and rules to make sure we are following the law and spending money correctly. 
• The U.S. Department of Health and Human Services (HHS) OIG: Search the HHS OIG reports for federal audit results.
• Centers for Medicare & Medicaid Services (CMS): CMS investigates program activities and provides funding, guidance and oversight tools to the state.

Checking the Data

We look at big data to find patterns. We use claims data from our fee-for-service and HealthChoice managed care program to see if any providers are billing much more than others for the same service. This helps us find red flags to investigate.

Data is great for finding patterns that look suspicious. However, if you look at the numbers alone without checking the facts, you might reach the wrong conclusion. That is why we use data to start an investigation, not to finish one.

Working with Managed Care Organizations (MCOs)

Most people in Maryland Medicaid get their health care through an MCO. Because most of our budget goes to these plans, we watch them very closely to protect your tax dollars.

The state pays these health care companies a set monthly fee for each member. In return, the MCO must provide all the contracted medical care that person needs. 

How We Watch Over MCOs

We use strong contracts to hold MCOs accountable. These tools make sure they follow the rules:

• Internal Audit Teams: Every plan must have a compliance officer and a committee to check their own work.
• Staff Training: All MCO leaders and employees must know how to spot and report fraud.
• Network Checks: We regularly check that each plan has enough doctors and specialists for our members.

Making Sure Money is Spent on Care

We want to make sure the money we give to MCOs goes to doctor visits and medicine, not just for the company's profit. We use these strategies:

• Medical Loss Ratio and Profit Cap: This measures how much money a plan spends on actual medical care compared to what they spend on office costs and profit. The total profit for all nine HealthChoice MCOs is capped at 1.3%.
• Shared Savings: If a plan saves a lot of money or loses too much, we have risk corridors to share those savings or losses between the state and the plan. 
• Quality Targets: We may hold back part of a plan’s payment until they prove they are meeting high-quality health goals for their members.

When an MCO Fails to Meet Quality Care Standards

If an MCO does not meet our high standards, Maryland takes action. We use a series of consequences:

• Corrective Action Plans: We give the plan a specific to-do-list to fix their mistakes.
• Fines: We can charge the plan money, or penalties, for not following the contract.
• Withholding Money: We can stop payments to the plan until they fix the problem.
• Banning: In the most serious cases, we can kick a plan out of the Maryland Medicaid program entirely.

Understanding Payments and Errors 

How We Measure Success: The PERM Program

The Payment Error Rate Measurement (PERM) program is a regular audit by the federal government to make sure Maryland Medicaid is making proper payments – that is following the rules and keeping the right paperwork for every payment it makes.

What is an improper payment? 

When the government finds an improper payment, it usually does not mean fraud. Most of the time, it is a paperwork mistake.

• Almost 80% of errors happen because a document is missing or incomplete.
• Example: A worker might correctly decide someone is eligible for Medicaid, but they forget to save a copy of the person's proof of income. This counts as an error even though the person was eligible.

Improving Our Process 

When the federal government finds these mistakes, Maryland creates a corrective action plan (CAP). This is a step-by-step list of how we will fix the paperwork issues and train our staff to do better.