The Missouri Medicaid Audit and Compliance Unit (MMAC) is responsible for reviewing participants who may be subjecting the Medicaid program to fraud, waste and abuse. This includes a review of a variety of factors which include:
- The number of physicians prescribing services to a particular participant;
- The number of pharmacies used to obtain prescriptions;
- The frequency of refills or overlapping prescriptions;
- The number of emergency room visits, and
- The services received.
If a MO HealthNet participant is found to be misutilizing MO HealthNet benefits, the individual can be restricted to a physician/clinic, pharmacy, or both in accordance with 13 CSR 70-4.070, and may also be referred to the appropriate authorities for possible healthcare fraud investigation and prosecution.
If you suspect a participant is abusing Missouri Medicaid, you may report the suspicion to mmac.lockin@dss.mo.gov. It is helpful if you can provide the MO HealthNet participant’s name, Medicaid DCN, address, date of birth and/or social security number, and a complete description of the complaint. You can find further information regarding the Lock-In program at https://mmac.mo.gov/participants/participant-lock-in/
The Department of Social Services MO HealthNet Fee-For-Service Participant Handbook advises MO HealthNet participants of the following:
Committing MO HealthNet fraud or abuse is against the law. Fraud is a dishonest act done on purpose. Examples of participant fraud are:
- Letting someone else use your MO HealthNet health insurance card
- Getting prescriptions with the intent of abusing or selling drugs
- Using forged documents to get services
Abuse is an act that does not follow good practices. Examples of participant abuse are:
- Going to the emergency room for a condition that is not an emergency
- Misusing or abusing equipment that is provided by MO HealthNet
- Getting services from multiple providers of the same kind
- Trying to get more services than are necessary
Please submit any questions to MMAC.Lockin@dss.mo.gov