The Medicaid Fraud division is divided into three units: Fiscal Integrity; Investigations; and Regulatory Office.
The Fiscal Integrity Unit is made up of the Division's Audit, Data Mining, Recovery and Exclusion, and Third-party Liability units.
The Audit Unit conducts audits and reviews of Medicaid providers' billings to ensure compliance with program requirements and, where necessary, to recover overpayments. These activities serve to: monitor the cost-effective delivery of Medicaid services to ensure the prudent stewardship of scarce dollars; ensure the required involvement of professionals in planning care for program recipients; safeguard the quality of care, medical necessity and appropriateness of Medicaid services provided; and reduce the potential for fraud, waste, and abuse. For information on the audit process, please view our Audit Guide Book.
The Recovery and Exclusions Unit sends out Notices of Claim and Notices of Demand, works with federal authorities to ensure the federal government receives its share of a recovery once a recovery is identified and/or received, works with the Division of Medical Assistance and Health Services to ensure fraudulent and excluded providers are terminated, recovers improper payments and collects interest, damages, and penalties from providers and recipients on behalf of the State of New Jersey and where necessary excludes or terminates a provider from the Medicaid program.
The Data Mining Unit looks for unusual patterns in claim reimbursement from providers and refers findings to the Audit or Investigations Units for further analysis.
Since Medicaid is the payer of last resort, the Third Party Liability Unit (TPL), working with an outside vendor, seeks to determine whether Medicaid beneficiaries have other insurance. If the recipient has other insurance, TPL recovers money from the private insurer.
The Investigations Unit examines and analyzes the activities of various medical providers including adult medical daycare facilities, pharmacies, durable medical equipment (DME) providers, and laboratories. When an investigation reveals an overpayment made to a provider or recipient as a result of fraud, waste or abuse, the investigator will refer the case upon completion to Recovery and Exclusions to seek recovery of any monies paid and to exclude the provider, where appropriate, from the program. If the conduct is also criminal in nature, the unit will refer the case to the New Jersey Medicaid Fraud Control Unit for additional investigation.
The Special Projects Unit reviews provider applications for DMEs, pharmacies, laboratories, and adult medical day care centers to verify that potential Medicaid providers have no outstanding criminal or disciplinary complaints.
The Division's Regulatory Unit reviews provider exclusion and termination decisions, represents the Division in all Administrative Law hearings, guides the Investigations Unit and provides guidance regarding pending legislation and proposed changes to existing Medicaid regulations.