Program Integrity

Equitable Oversight Design for Program Integrity Leaders

Design program integrity reviews that prevent and address fraud while staying proportionate, avoiding profiling, protecting due process and continuity of care, and communicating accurately.

About 48 minutes, plus optional practice · 4 lessons · Voluntary learning

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Course outline

Two kinds of harm: fraud and careless enforcement
Explain how fraud harms people who rely on public programs, not only public budgets.
12 minutes
Proportionate reviews that target conduct, not communities
Distinguish risk indicators based on conduct or billing patterns from proxies for race, national origin, language or disability.
12 minutes
Due process: notice, appeal rights and continuity of care
Explain the core due process elements recognized in Goldberg v. Kelly.
12 minutes
Using data responsibly and communicating with care
Explain why an analytic flag is a lead for review rather than a finding.
12 minutes

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What you’ll be able to do

Explore and practice

Explain how fraud harms people who rely on public programs, not only public budgets.
Distinguish risk indicators based on conduct or billing patterns from proxies for race, national origin, language or disability.
Explain the core due process elements recognized in Goldberg v. Kelly.
Explain why an analytic flag is a lead for review rather than a finding.

What you can take into your work

Explain the distinction tested in each knowledge check.
Compare the responses to each fictional case and the reasons behind them.
Complete the course job aid for a situation you choose.

Choose one data flag or report your area uses. Find out how many flagged cases were confirmed after review in a recent period and whether that rate differs by provider size or region. If you cannot find out, write down what data would be needed and who owns it.

Equitable Oversight Design for Program Integrity Leaders: practice guide

A reusable guide for a situation you choose

Design program integrity reviews that prevent and address fraud while staying proportionate, avoiding profiling, protecting due process and continuity of care, and communicating accurately.

Use observable details rather than assigning motives.
Invite perspectives without requiring personal disclosure.
Keep learning separate from individual assessment or personnel decisions.

Design proportionate reviews

Label each issue precisely: error, improper payment, waste or abuse, or credible fraud indicator.
Use tiered responses with written criteria: education, targeted review, corrective action, recovery, withhold, referral.
Select for review on conduct and billing patterns, not identity proxies.
Test selection criteria for disparate effects and accuracy before use; refer legal questions to counsel and EOAD.

Protect due process

Notices state the action, effective date, specific reasons, supporting rules and appeal rights.
Follow Medicaid advance notice and continuation-of-services rules for people served.
For provider suspensions, follow 42 CFR 455.23 notice content and consider good cause exceptions, including access.
Plan continuity of care with counties, Tribal Nations and case managers.

Use data and words carefully

Treat every flag as a lead; verify records and consider innocent explanations.
Track confirmation rates and false positives by provider type and region.
Describe conduct, never communities, in public statements; coordinate with communications and legal.
Report fraud results and access effects together.

Try the guide and revisit it

Choose one data flag or report your area uses. Find out how many flagged cases were confirmed after review in a recent period and whether that rate differs by provider size or region. If you cannot find out, write down what data would be needed and who owns it.
Privately consider how a public statement about fraud might be heard by a family that receives services lawfully from a provider in the same community. What would you want them to hear?

Participation and course completion in this program do not count toward DHS-required training credits unless management, a director, or DHS leadership expressly approves an exception.

Sources and further reading

Minnesota Department of Human Services — Program Integrity
Supports the description of DHS program integrity work under the Office of Inspector General, including high-risk service designation, revalidation, enrollment pauses, payment withholds, third-party billing review and resources to help people find care. Specific figures on the page are time-sensitive and are not repeated in the course.
U.S. Government Accountability Office — A Framework for Managing Fraud Risks in Federal Programs (GAO-15-593SP)
Supports the four components (commit, assess, design and implement, evaluate and adapt), the emphasis on prevention and the discussion of fraud risk tolerance and weighing program objectives. Written for federal managers; applied here by analogy.
Centers for Medicare and Medicaid Services — Medicaid Program Integrity
Supports shared federal-state responsibility for program integrity, the distinction between improper payments and fraud, waste and abuse, and the emphasis on data.
Electronic Code of Federal Regulations — 42 CFR 455.23, Suspension of payments in cases of fraud
Supports the credible allegation of fraud standard, notice timing and content, and good cause exceptions including jeopardized beneficiary access.
Electronic Code of Federal Regulations — 42 CFR part 431, subpart E, Fair Hearings for Applicants and Beneficiaries
Supports notice content, advance notice timing and exceptions, the right to a hearing and continuation of services pending a hearing decision.
Justia — Goldberg v. Kelly, 397 U.S. 254 (1970)
Supports the due process elements for termination of public assistance described in lesson 3.
U.S. Department of Justice, Civil Rights Division — Title VI Legal Manual, Section VII: Disparate Impact
Supports the effects standard and three-part analysis applied to review selection criteria in lesson 2. Formal determinations belong to counsel and enforcement agencies.

All research and sources across the program

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Course outline

Two kinds of harm: fraud and careless enforcement

Explain how fraud harms people who rely on public programs, not only public budgets.

12 minutes

Proportionate reviews that target conduct, not communities

Distinguish risk indicators based on conduct or billing patterns from proxies for race, national origin, language or disability.

12 minutes

Due process: notice, appeal rights and continuity of care

Explain the core due process elements recognized in Goldberg v. Kelly.

12 minutes

Using data responsibly and communicating with care

Explain why an analytic flag is a lead for review rather than a finding.

12 minutes

Sources and further reading

Minnesota Department of Human Services — Program Integrity

Supports the description of DHS program integrity work under the Office of Inspector General, including high-risk service designation, revalidation, enrollment pauses, payment withholds, third-party billing review and resources to help people find care. Specific figures on the page are time-sensitive and are not repeated in the course.

U.S. Government Accountability Office — A Framework for Managing Fraud Risks in Federal Programs (GAO-15-593SP)

Supports the four components (commit, assess, design and implement, evaluate and adapt), the emphasis on prevention and the discussion of fraud risk tolerance and weighing program objectives. Written for federal managers; applied here by analogy.

Centers for Medicare and Medicaid Services — Medicaid Program Integrity

Supports shared federal-state responsibility for program integrity, the distinction between improper payments and fraud, waste and abuse, and the emphasis on data.

Electronic Code of Federal Regulations — 42 CFR 455.23, Suspension of payments in cases of fraud

Supports the credible allegation of fraud standard, notice timing and content, and good cause exceptions including jeopardized beneficiary access.

Electronic Code of Federal Regulations — 42 CFR part 431, subpart E, Fair Hearings for Applicants and Beneficiaries

Supports notice content, advance notice timing and exceptions, the right to a hearing and continuation of services pending a hearing decision.

Justia — Goldberg v. Kelly, 397 U.S. 254 (1970)

Supports the due process elements for termination of public assistance described in lesson 3.

U.S. Department of Justice, Civil Rights Division — Title VI Legal Manual, Section VII: Disparate Impact

Supports the effects standard and three-part analysis applied to review selection criteria in lesson 2. Formal determinations belong to counsel and enforcement agencies.