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Title 8: Medicaid Page 42 Iowa Department of Health and Human Services Employees’ Manual Chapter G: Case Maintenance Fraud and Overuse of Medicaid Services Revised November 4, 2022
Fraud and Overuse of Medicaid Services Legal reference: 441 IAC 79.2 If you become aware of a situation where it appears that Medicaid services are being overused or excessive or inappropriate Medicaid services are being provided, email the details to FWAReports@dhs.state.ia.us. If you become aware of any situation that indicates potential fraud by a medical provider, report the circumstances to the IME Program Integrity Unit at 1-877-446-3787 or in Des Moines at 515-256-4615. Examples of such situations include: ▪ Billing for services, supplies, or equipment that were not rendered to or used for members. ▪ Billing for supplies or equipment that is clearly unsuitable for the member’s needs or so lacking in quality or sufficiency for the purpose as to be virtually worthless. ▪ Flagrant and persistent overutilization of medical or paramedical services with little or no regard for results, the member’s ailment, conditions, medical needs, or the doctor’s orders. ▪ Claiming of costs for noncovered or nonchargeable services, supplies, or equipment disguised as covered items. ▪ Material misrepresentations of dates and descriptions of services rendered or of the identity of the member or the person who rendered the services. ▪ Duplicate billing that appears to be deliberate, e.g., billing twice for the same services. ▪ Arrangements by providers with employees, independent contractors, suppliers, and others that appear to be designed primarily to overcharge the Medicaid program using various devices to siphon off or conceal illegal payments. ▪ Charging to the Medicaid program by subterfuge costs that were not incurred or that were attributable to nonprogram activities, other enterprises, or personal expenses.