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Office of Program Integrity (OPI)

The OPI is charged with meeting the requirements set forth in:

  • Title 42 CFR Section 455.1 Program Integrity: Medicaid – Requirements for a State fraud detection and investigation program and
  • Title 42 CFR Section 456.1, Utilization Control – Requirements concerning control of the utilization of Medicaid services

Title 42 CFR Section 455 13 states, "The Medicaid agency must have:

  • Methods and criteria for identifying suspected fraud cases; 
  • Methods for investigating these cases that—
     
  •             (1)   Do not infringe on the legal rights of persons involved; and 
                (2)   Afford due process of law; and
     
  • Procedures developed in cooperation with State legal authorities for referring suspected fraud cases to law enforcement officials.

The OPI executes the federal requirement of Title 42 CFR Section 456.3 which states, “The Medicaid agency must implement a statewide surveillance and utilization control program that&mdash

  • Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments;
  • Assesses the quality of those services;
  • Provides for the control of the utilization of all services provided under the plan in accordance with subpart B of this part; and
  • "Provides for the control of the utilization of inpatient services in accordance with subparts C through I of this part.”

The OPI conducts post-payment reviews. OPI is responsible for identifying fraud, waste, and abuse cases and uses a combination of processes and claims data systems to complete this task. The processes and claims data systems detect fraud, waste, and abuse by reviewing member and provider information.

Additional information related to OPI and its processes can be found at:http://www.dhhr.wv.gov/bms/Documents/Chapter_800B_QPI.pdf