Monitor and Audit Providers Who Participate in Wisconsin Medicaid

The Medical and Program Audit Review Sections focus on preventing, detecting, and investigating provider fraud, waste, and abuse in Wisconsin’s Medicaid program. Staffers:

• Audit providers to ensure compliance with Medicaid rules and regulations.
• Investigate allegations of fraud, waste, and abuse.
• Provide education and technical assistance to providers through audit activities.
• Recommend new policies, or policy changes, that protect and promote Wisconsin Medicaid.
• Review, track, and research provider billing.

We detect and prevent fraud and abuse throughout the provider payment process.

Before payment:

• Conduct on-site visits to high-risk providers before Medicaid certification.
• ​Educate providers and beneficiaries about Medicaid rules and regulations.
• Ensure contracts with providers contain language that helps prevent fraud, waste, and abuse.
• Mandate that providers register to become Medicaid-certified.

During Claims Processing:

• Ensure the claims processing system has edits and audits in place to prevent medically unlikely claims (e.g. age/gender mismatch).
• Intervene manually as needed.
• Suspend provider payments when there are credible allegations of fraud.

Post-Payment:

• Conduct audits and reviews of providers for compliance with Medicaid rules and regulations.
• Issue Explanation of Benefits to members to assist in reporting of fraudulent claims.
• Provide Remittance Notices to providers for review of payments for possible errors.
• Refer suspected cases of fraud, waste and abuse to law enforcement, and assist in investigations.
• Utilize comment grids to locate relevant state and federal law. Wisconsin Medicaid Services Providers can access the OIG Post-Payment Review Comment Grids on the FowardHealth Provider Portal.