Audit Medicaid Integrity Contract (Audit MIC) Overview

The Centers for Medicare & Medicaid Services (CMS) created new entities entitled Audit Medicaid Integrity Contractors (MIC) in order to continue its efforts to ensure the highest integrity of its healthcare programs. The goal of the provider audits is to identify overpayments and to ultimately decrease the payment of inappropriate Medicaid claims.  The role of an Audit MIC is to review claims submitted by all types of Medicaid providers, including all settings of care and types of services, with most audits taking place at staff headquarters and on occasion on-site at a provider’s place of business. An overview of the Medicaid Integrity Program (MIP) can be found at CMS’ Medicaid Integrity Program website, where CMS publications pertaining specifically to audits and the MICs can be found under the “Provider Audits” Section.

CMS provides the Audit MIC with a list of providers identified for audit based on information provided by Review MICs. The Review MICs are separate CMS contractors whose role is to conduct analysis of Medicaid claims data to identify aberrant claims and potential billing vulnerabilities.  

On September 4, 2009, CMS awarded Health Integrity, LLC (HI) the Audit MIC Task Order 5 (TO5) contract to perform audits of Medicaid providers in 10 states in the Midwest region. The states included in the TO5 contract are Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, Ohio, and Wisconsin.

On September 16, 2009, HI was awarded the Task Order 1R (TO1R) contract to perform audits of Medicaid providers in the Southeast region of the U.S. from Pennsylvania to Florida.  The states included in the TO1R contract Alabama, Delaware, Florida, Georgia, Kentucky, Maryland, Mississippi, North Carolina, Pennsylvania, South Carolina, Tennessee, Virginia, West Virginia and the District of Columbia. In combination with the TO5 contract, HI is responsible for conducting audits in 23 states and the District of Columbia.

A provider may be selected for one of three different types of audits to be performed - a focused or comprehensive review that is performed as a desk audit or may be performed as an onsite audit at the provider’s facility, or a cost report audit. HI manages its workload from offices located in Easton, Maryland and is supplemented by staff located throughout the regions in which it serves.  HI Staff includes auditors, audit investigators, medical claims reviewers and data analysts.

To contact representatives from the Audit MIC at Health Integrity, LLC, please call (866) 269-3494.

Other sources of information:

• Medicaid Integrity Program Fact Sheet
• Medicaid Integrity Program A-Z