program integrity annual surveyPage 1 of 2


Office of the Inspector General
F-02209 (05/2018) / STATE OF WISCONSIN

program integrity annual survey – 2017 data

Completion of this survey is voluntary and not required by Wisconsin statute. The information collected through this survey will be initially used by the Office of the Inspector General to establish baseline data and measure change.
INSTRUCTIONS: Please complete this survey using data from Calendar Year 2017. Only Medicaid data can be reported on this form. The respondent must exclude data from all other lines of business, including Family Care, PACE, and Partnership.
Surveys must be submitted by June 30, 2018 by email: .

section i – respondent information

Name – Respondent (Last, First) / Respondent’s Agency
Street Address
City / State / Zip Code / Phone Number
Email Address

section ii – survey questions (required)

Number of investigations opened for:
Fraud: Waste: Abuse: / “Investigations opened” refers to reports of fraud, waste, and abuse that resulted in further investigative action being taken.
Number of substantiated investigations for:
Fraud: Waste: Abuse: / “Substantiated investigations” refers to investigations that resulted in a disposition indicating that fraud, waste, or abuse occurred.
Number of cases referred to OIG for:
Fraud: Waste: Abuse: / “Referred to OIG” refers to all cases submitted to OIG using OIG’s hotline or the fraud reporting portal.
Amount recovered from investigations for:
Fraud: Waste: Abuse: / “Amount recovered” refers to the amount the plan recoups from network providers as a result of a fraud, waste, or abuse investigation.
Amount suspended due to a credible allegation of fraud:
Amount: / “Amount suspended” refers to the amount the plan help pending the outcome of a credible allegation of fraud suspension. “Credible allegation of fraud suspension” refers to providers for whom the OIG has suspended Medicaid payments.
Number of providers terminated due to fraud, waste, or abuse: / “Terminated” refers to network providers whose contracts with the plan were ended due to fraud, waste, or abuse.
Number of provider self-audits completed:
Required by plan: Initiated by provider: / “Self-audits” refers to any audit that the network providers complete on their own billing practices and report the outcome to the plan.
Amount recovered through provider self-audits:
Required by plan: $ Initiated by provider: $ / Enter the number of dollars recouped by the plan (or otherwise returned to the plan by the network providers) as a result of self-audits. Enter separate dollar amounts for each entity initiating the self-audit.
Number of explanation of benefits (EOBs) sent to members: / “EOBs” refers to documents sent to members that give them the opportunity to identify claims that were processed for which they did not receive the service. EOBs typically contain, at minimum, the date of service, provider name, provider location, and service provided.
Number of complaints related to EOBs submitted by members: / “Complaints” refers to the number of phone calls or other notifications that a network provider is potentially committing fraud, waste, or abuse. The number of complaints reported in this box must be directly attributed to the EOB.
Number of employees dedicated to the Special Investigation Unit: / “Special Investigation Unit (SIU)” refers to the plan’s employees who are tasked with program integrity activities. If a person dedicates half of his/her time to SIU activities, count that person as “0.5.”

section iII – additional information (optional)

Provide any additional information as it pertains to the plan’s program integrity efforts, for example, information related to new program integrity initiatives implemented during the reporting period.
My printed name and date indicate that the information provided above is true and accurate to the best of my knowledge.
Name – Respondent / Date Completed