Program integrity

Program integrity provides accountability and ensures that taxpayer dollars are spent efficiently. The Program Integrity 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 :

What is fraud and how to report it

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:

Falsifying claims/encounters
Double billing
Billing for services not provided
Accepting kickbacks for referring Medical Assistance patients to a particular provider
Billing for services for a recipient or provider who is incarcerated or deceased
Billing inflated hours to an agency providing home healthcare
Failing to accurately report on applications who and how many people make up a household
Forging or altering documentation
Receiving benefits in more than one state at a time
Underreporting income to receive MinnesotaCare, SNAP or other benefits.

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

Key functions

Health care provider investigations and audits

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.
Minnesota Restricted Recipient Program
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:
- 651-431-2648
- 800-657-3674
Restricted Recipient Program Client Brochure DHS-4659 (PDF)

Restricted Recipient Program Brochure DHS-6752 (PDF)
Child care investigations
- Early and Often Team. Child care center licensors and child care investigators work closely with applicants for child care center licenses and newly licensed providers offering technical assistance to increase compliance and reduce errors.
- Child Care Assistance Program provider investigations. This unit investigates and takes appropriate action if child care providers violate rules or laws relating to the state’s Child Care Assistance Program. Actions include administrative remedies to stop and recover payments, and referrals to law enforcement agencies.
- Child Care Grant Audits. Investigators conduct compliance checks and audits of licensed child care centers and those providers that receive grants. Statewide, random audits and compliance checks are designed to ensure program integrity.
Recipient investigations
- Recipient fraud investigations. Through the Fraud Prevention Investigation (FPI) program, DHS works with counties to investigate recipient fraud. It administers annual grants that fund investigator positions covering 86 Minnesota counties. Tribes can now apply to be part of the FPI program.
- MinnesotaCare investigations. This unit investigates eligibility when a recipient’s health care is provided through MinnesotaCare.