Program Integrity

Targeting fraud, waste and abuse

The Center for Health Care Financing’s Program Integrity division is dedicated to ensuring compliance and accountability within the Massachusetts Medicaid program by detecting and preventing fraud, waste, and abuse. Staff members construct algorithms to identify regulatory noncompliance and to ferret out erroneously paid claims.

The Center focuses on two major areas:

• Compliance Audits
  The staff ensures that Medicaid billing functions are conducted correctly and fulfill all federal requirements
• Provider Compliance and Recovery
  The staff designs and oversees initiatives that root out Medicaid fraud, waste, and abuse. For example, the expense of transportation trips should not be covered when a Medicaid member residing in a skilled nursing facility has no associated claims for medical or home health services.