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OIG Post-Payment Review

Office of the Inspector General Post-Payment Review

The Office of the Inspector General (OIG) has reformed its operating procedures for post-payment auditing and review of claims. To assist the OIG staff locate relevant state and federal law, OIG developed a tool called the “Comment Grids.” These grids list some common audit findings that are discovered during a case review and assist staff to identify applicable statutes and administrative code provisions. Grids are developed for specific service provider types and service areas that are commonly reviewed by OIG. These grids are not to be used by service providers as a checklist, legal advice, or exhaustive resource to ensure compliance with Medicaid requirements.

These grids include the following information:

  • Audit Finding: The category, or finding, within a service provider type to which documentation reviewed in the audit indicates potential non-compliance with state authority.
  • Comment: The sub-category, or comment, to which the documentation reviewed indicates specific service provider non-compliance with state authority.
  • Description: Additional details and examples of how the audit documentation can indicate that the service provider was non-compliant with applicable law.
  • Wisconsin Administrative Codes: The current codes used as authority for the related findings and comments.
  • Wisconsin State Statutes: The current statutes used as authority for the related findings and comments.
  • Revision Date: The date that the comment grid was revised and published online.

The grids are anticipated to be an evolving tool that is updated to reflect any changes to federal or state law or auditing practices. OIG has developed grids for service provider types that are historically high risk for fraud, waste, and abuse according to the Affordable Care Act, other federal guidance, and noted provider trends within Wisconsin. OIG may conduct post-payment reviews of service providers and provider types not listed in these grids. The findings and related content detailed within the grids are not exhaustive, and OIG may reference other findings and/or law or code provisions according to the individuality of the case and documentation provided during the post-payment review.

These grids may be referenced by service providers and the public as informational regarding the operational work of OIG. Service providers are required to abide by all state and federal laws and regulations. These grids are not to be used by service providers as a checklist, legal advice, or exhaustive resource to ensure compliance with Medicaid requirements.

Comment Grids by Provider Type

Provider Type Resources
Ambulance Services More Information
Chiropractic Services More Information
Community Support Programs More Information
Comprehensive Community Services More Information
Dental Services More Information
Durable Medical Equipment and Disposable Medical Supplies More Information
Family Planning More Information
Home-Health Inpatient Overlap More Information
Laboratory Services More Information
Metastar More Information
Mental Health/Alcohol and Other Drug Abuse Services More Information
Personal Care Services More Information
Pharmacy More Information
Physician More Information
Private Duty Nursing More Information
Specialized Medical Vehicles More Information
Therapies More Information
Third Party Liability More Information
 
 
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