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
