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Surveillance and Utilization Review

It is important to have an effective way to protect the integrity of the Montana Medicaid Program. Between 7 and 14 percent of all health-care expenditures are improperly made, according to government estimates.

The program that protects the integrity of Montana Medicaid from fraud and abuse is known as the Surveillance and Utilization Review (SURS) Unit. The SURS program guards against fraud and abuse by providers. It identifies aberrant billing practices, sanctions those who have abused Medicaid, recovers overpayments, and assists in criminal investigations where appropriate.

SURS performs a variety of other functions, such as detecting loopholes in Medicaid regulations, finding contradictions in policy, and preventing fraud and abuse from occurring.

Types of Provider Fraud/Abuse

Provider fraud is the criminal act of intentionally filing a false claim. Typically, the claim is for services that were not actually rendered. Abusive billing by providers that is not fraudulent is the most common cause of loss and accounts for the greatest financial loss to the Medicaid program. It may take the form of billing for excessive services, consistently billing for the most expensive services possible, patient sharing, or rendering medically unnecessary services. These are only a few of the many devices used to over-bill Medicaid. Proving fraud can be difficult and requires expert investigation and analysis.

In addition, program losses can result from innocent billing errors. SURS distinguishes among the various kinds of losses and applies the appropriate solution. When there is reliable evidence of fraud, the provider is referred to the state's Medicaid Fraud Control Unit of the Attorney General's Office for criminal investigation.

Detecting Fraud and Abuse

SURS does not conduct random audits. Providers and recipients are selected for review based on creditable information that points to an irregularity. The heart of the detection process is a sophisticated computer program that screens all provider billing and recipient services to flag aberrant practices. Once such practices are identified, the provider or recipient is then reviewed.

There are various other means of identifying non-compliant providers and recipients. SURS receives referrals from other governmental entities and from the public.

Sanctions

When an analysis of a provider's records shows that program rules have been violated, a sanction may be imposed. This may range from a warning letter to a criminal charge. No sanction is imposed without concrete evidence, and a provider may formally appeal a sanction.

What You Can Do

If you suspect fraud or abuse by an enrolled Medicaid provider, you may call one of the Program Compliance Bureau's fraud hotlines:

Recipient eligibility fraud, 800-201-6308
Provider fraud, 800-376-1115

You may report anonymously, but the Bureau prefers to have a way to contact you in case we need more information.

For more information about SURS

Program Compliance Bureau Chief
406-444-4120

SURS Supervisor
406-444-4586

Page last updated: 08/01/2013