Program Integrity

Provider fraud, waste, and abuse can involve physicians, pharmacists, and medical equipment companies.  

The professional staff of the Program Integrity Section includes nurse reviewers, claims reviewers and data analysts to detect inappropriate payments to Medicaid providers.  Our goal is to conduct monitoring of Medicaid providers for compliance with Medicaid statutes and rules, and to recover inappropriate payments from Medicaid providers.  Compliance monitoring includes administration of the program to educate employees of providers about false claims.

We also conduct preliminary investigations on suspected fraud.  The Program Integrity Section works closely with the Colorado Medicaid Fraud Control Unit at the State of Colorado Attorney General’s office regarding suspected fraud. 

In addition to staff efforts, the Department contracts for additional services to prevent, detect and recover overpayments and identify suspected fraud through our Recovery Audit Contract (RAC) and the Diagnosis Review Code Contract (DRG).

You can help us by reporting suspected fraud, waste or abuse by Medicaid providers or Medicaid members.

You may also contact the Office of Inspector General, U.S. Department of Health and Human Services Fraud Hotline