Medicaid Program Integrity

This business unit is responsible for contract oversight, special investigations, recipient investigations and clinical teams. It handles intake and triage of cases before turning them over to the Medicaid Fraud Control Unit (MFCU) of the Georgia Attorney General’s office.

The purpose of the unit is to guard against fraud, abuse and deliberate waste of Medicaid Program Benefits. Medicaid Program Integrity ensures that Georgia taxpayer funds are used in a responsible manner. The unit also has oversight of state and federal funds.

Medicaid Program Integrity also ensures that eligible members have access to health care facilities and health care professionals to receive quality care through the state of Georgia. It educates providers about compliance regulations in accordance with the policies and procedures established by state and federal guidelines.

In accordance with the Health Information Portability and Accountability Act (HIPAA), the unit is also responsible for assuring that all Personal Health Information (PHI) is handled in a safe and secure manner during the collection and review processes.

Medicaid Program Integrity works with a variety of regulatory agencies, including, but not limited to, the Medicaid Fraud Control Unit, Medicare Zone Program Integrity Contractors, and the Office of the Inspector General for Health and Human Services.

Here is information about the agency’s Recovery Audit Contractor (RAC).