Hello, it’s a valid question. We (Louisiana) have asked questions like this to our actuaries before, and generally the actuaries tend not to be concerned about SIU or Program Integrity recoveries, because the service dates tend to be old enough that they do not affect future rates. Our MCOs report financials quarterly, including income…

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The UPIC makes referrals to CMS and OIG (Federal law enforcement) via the MCC process. The State and MFCU attend the MCC call. The State does not see the referral for up to 7 days after the MCC meeting. The State has no communication with OIG (Federal), only MFCU (state) and UPIC (Federal). For the UPIC, once the referral is submitted to…

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In Louisiana, we can do prepay for FFS, but it’s not broadly used and there are no specific parameters mentioned in the Louisiana Administrative Code about scenarios when we would pend claims. Our MCOs use it, though, and most of them only put a provider on prepay if an audit showed possible fraud or abuse. Prepay for those MCOs tends to…

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