The Office Of Program Integrity

What is it?

The Office of Program Integrity (OPI) ensures compliance, efficiency, and accountability within the health and human services programs administered by the State of Rhode Island by detecting and preventing fraud, waste, and program abuse and ensuring that state and federal dollars are spent appropriately, responsibly, and in accordance with applicable laws.

How do we protect our program integrity in RI?

Fraud and Abuse

  1. The EOHHS Office of Program Integrity has developed protocols and procedures to detect and deter fraud, waste and abuse.
  2. To increase accountability and transparency, the EOHHS is putting more information online, specifically detailing the number of beneficiaries of certain services and associated costs.
  3. The OPI is focusing on all publicly funded health and human services programs, not just SNAP and Medicaid, using sophisticated data mining and modeling techniques to identify unusual patterns of purchasing and billing by third parties.

Guiding Principles

The Office of Program Integrity

  1. Strives to achieve the most cost efficient health care system possible while further enhancing the quality and appropriateness of services delivered.
  2. Requires and supports efforts that enable health care providers to identify and resolve issues themselves.
  3. Holds provider agencies accountable for building and maintaining systems to prevent improper billing.
  4. Increases the usage of the administrative tools such as payment suspension, prepayment review, audit, sanction, and individual and entity exclusion when improper payments are discovered.
  5. Develops and communicates consistent measures of the effectiveness of program integrity that capture cost reduction and avoidance, as well as recoveries, and minimize costs imposed by reviews and investigation.
  6. Recognizes areas of vulnerabilities that adversely affect program integrity.

How to Report Fraud & Abuse

If you have information related to a suspected incident of fraud, waste or abuse, please contact:

  • Department of Human Services Fraud hotline for reports on CCAP, SNAP, RIWorks and GPA at (401) 415-8300;
  • Department of RI Attorney General for reports on Medicaid fraud, Patient Abuse or Neglect, or Drug Diversion at (401) 222-2556 or (401) 274-4400 ext. 2269;
  • EOHHS Office of Program Integrity for assistance on any publicly funded health and human services program at (401) 462-6503.

Fraud and Abuse Investigations

The Office of Program Integrity is committed to identifying fraud, waste and abuse in Medicaid and in all health and human service programs. The OPI actively pursues any leads indicating fraudulent practices and uses them as a source to begin investigations. To increase our effectiveness, the OPI is partnering with Medicare and Medicaid insurance companies to share information about fraudulent activity and to conduct joint investigations.

The OPI also receives complaints from patients, their families, other providers, former employees of a provider, and through federal and state referrals. Office staff triage and investigate every valid complaint.

Decisions rendered by the review process can result in refunds to the program for inappropriate payments, training on how to correct or improve billing practices, referral to licensing boards, and/or referral to the RI EOHHS Office of Program Integrity and the RI Office of the Attorney General for suspected fraudulent practices.