Program Integrity (PI) is responsible for monitoring and safeguarding the fb88Care program against fraud, abuse and waste through an audit process, driven by referrals from other state agencies, health care providers, and members as well as fb88Care billing analysis to detect utilization patterns or trends.
fb88 DHHS Policy Guidance
Provider Reviews
Program Integrity conducts on-going audits/reviews of all fb88Care providers and their claims for services.ÌýPI reviews generally consist of claims data information and the clinical/professional/financial record supporting the services or products that were billed to, and paid for by the fb88Care Program.ÌýThe focus of the reviews is to ensure that billings are in compliance with all fb88Care rules and regulations and to detect and deter areas of fraud, abuse, and waste.
Fraud, Abuse, and Waste
Examples of fraud, abuse, and waste include, but are not limited to:
- Billing for services not provided;
- Billing for medically unnecessary services;
- Billing for non-covered services disguised as a covered service;
- Pre-billing services;
- Listing phantom employees on budgets used for rate setting;
- Poor or no documentation to support the services billed.
How to Report FraudÌý
If you are looking to report allegations of fraud, or attempted fraud, involving funds administered by fb88 DHHS:Ìý
Option 1: Complete the Online Reporting Form.  Ìý
Option 2: Email PI.DHHS@maine.gov.Ìý
Option 3: Call the Fraud Hotline:Ìý1-866-348-1129 or (207) 287-4660. TTY users dial 711.Ìý
Exclusion ProgramÌý
Program Integrity (PI) administers the Department of Health and Human Services' (DHHS) fb88Care Exclusion Program. Excluded individuals or entities are prohibited from enrolling as fb88Care providers or servicing providers. In addition, fb88Care providers are prohibited from employing, directly or indirectly, excluded individuals or entities. Federal regulations prohibit payment for any item or service furnished, ordered, or prescribed by an excluded individual.
Electronic Code of Federal Regulations
Screening for Excluded Individuals or EntitiesÌý
Providers are required under the fb88Care Provider/Supplier Agreement and the fb88Care Benefits Manual Chapter I, § 1.03-8Y to ensure that "excluded individuals or entities are not employed or utilized to provide services, receive payments, or submit claims, to the fb88Care Program."
We strongly recommend that you screen all your employees and contractors for exclusions. You should screen all new potential employees prior to hire and routinely screen all staff at set time intervals, i.e. annually, quarterly, etc. We also recommend that you require your contractors to screen their staff for excluded individuals. You should check both the state and federal websites. Someone may not be excluded by the federal government and fb88. See the Exclusion Databases (PDF)Ìýfor details about how to search for excluded individuals.
Exclusion Violations
There are consequences for a provider who employs or contracts with an excluded individual or entity, including reimbursement for paid services. For details, see the Effects of Employing or Contracting with Excluded Individuals or Entities (PDF).
Please immediately report any exclusion violations to Program Integrity.
Contact Information
- Program Integrity
- 11 State House Station
- Augusta, MEÌý 04333-0011
- (207) 287-4660