Program integrity provides accountability and ensures that taxpayer dollars are spent efficiently. The Program Integrity and Oversight Division identifies and prevents provider and recipient fraud, waste and abuse in public programs administered by DHS.
Some of the public benefit and economic assistance programs include :
Fraud is wrongful or criminal deception intended to result in financial or personal gain. Fraud includes false representation of fact, making false statements, or by concealment of information. Examples of fraud include:
Waste and Abuse are practices that result in unnecessary cost to health and public benefit programs, or payment for services that are not medically necessary.
To report fraud
Medicaid Provider Investigations. The Surveillance and Integrity Review Section (SIRS) investigates the billing and delivery of health care services by providers receiving payment through Medical Assistance, Minnesota’s Medicaid program. SIRS withholds payments when there are credible allegations of fraud, initiates appropriate sanctions, identifies and recovers overpayments, and refers suspected fraud to criminal investigative agencies.
Provider Screening. A SIRS unit conducts unannounced pre-and post-enrollment site visits of providers that are considered at moderate or high risk of committing fraud or abuse in Medical Assistance to verify compliance with enrollment standards.
MCO Oversight and Federal Audits. Staff oversee program integrity activities by managed care organizations (MCO) that contract with DHS to provide health care services for Minnesota Health Care program enrollees. They manage the work of federal and state contractors conducting program integrity reviews of providers and coordinate with federal oversight authorities.
The Minnesota Restricted Recipient Program (MRRP) provides case management for Medical Assistance enrollees who are overusing or abusing health care services. About 3,500 individuals participating in the program. Participants choose one primary care provider, one hospital and one pharmacy. The primary care provider coordinates the participants care, including referrals to specialists
The program was developed to improve safety and the quality of care, as well as reduce costs for Minnesota recipients who have misused or abused.
MRRP contact numbers:
Restricted Recipient Program Client Brochure DHS-4659 (PDF)
Restricted Recipient Program Brochure DHS-6752 (PDF)
