Compliance and Program Integrity

Ensuring compliance with financial regulations — while simultaneously maintaining the integrity of programs — can strain both the human and financial resources of health care agencies, nonprofit organizations, and Medicaid programs. At UMass Medical School’s Commonwealth Medicine division, our experienced professional and legal staff members make it easier to navigate the complexities of reaching compliance and program integrity goals.

Using large databases, algorithms, and data-mining technology, we are able to quickly identify the following problems:

  • Aberrant behavior
  • Overpayments
  • Potential fraud
  • Abuse activities

With our resources, nonprofit organizations, health care agencies, and state Medicaid programs can successfully comply with all applicable laws, policies, regulations, and standards. Our Center for Health Care Financing, for example, conducts detailed audits on behalf of the Massachusetts Medicaid program, MassHealth, to ensure that providers’ payments conform to state and federal regulatory mandates. Our auditors identify financial issues at hospitals, nursing homes, and other providers’ accounts receivable departments using these methods:

  • Targeted provider reviews
  • Desk audits
  • Field audits

Our Center for Health Care Financing has a unit dedicated to helping MassHealth meet and exceed federal requirements for program integrity. This group fulfills several essential roles:

  • Acts as liaison to the Attorney General’s Medicaid Fraud Control Unit
  • Ensures compliance with surveillance utilization review system (SURS) requirements for post-payment review of claims and provider profiling
  • Assesses provider compliance with regulations
  • Develops recovery initiatives

Every state Medicaid office is required to ensure the integrity of its program by rooting out fraud, waste, and abuse through SURS and regular audits of the claims payment system. Failing to meet these requirements can cause a state to lose federal financial support.

In FY 2008, our SURS initiatives detected the following improper claims — resulting in $2.3 million in revenue for the state of Massachusetts that otherwise would have been lost:

  • Independent transportation providers who billed for duplicate round-trip claims
  • Paid claims that should have been adjusted by nursing facilities
  • Providers who improperly calculated the time units and/or improperly added base units to time units for anesthesia claims