Office of the Inspector General (OIG) - Division of Surveillance Utilization Review Subsystem (SURS)

Thomas Russell, Inspector General       

Division of Surveillance Utilization Review Subsystem

About SURS

The SURS (Surveillance Utilization Review Subsystem) Division produces comprehensive reports that are used for the detection of Medicaid program fraud and abuse, quality of care, and the development of program policy.  

Mission

• To reveal and investigate potential misuse of Medicaid by individual participants.
• To provide information which will reveal and facilitate investigation of potential defects in the level of care or quality of service provided under the Medicaid Program.

Detecting Fraud and Abuse

The SURS division has the capability to manipulate Medicaid data in such ways to identify usage trends. There are many ways that manipulated data can be used.

• Create profiles of the fee-for-service and encounter data of any participant in the program including providers, MCOs and recipients.
• Classify providers within their peer groups in order to establish norms and thereby identify atypical practices.
• Develop ad hoc reports to review areas of potential fraud, abuse and quality of care issues.

Examples of Provider Fraud

• Billing for services that were not provided, e.g., a hip x-ray that was not taken.

• Duplicate billing which occurs when a provider bills Medicaid and also bills private insurance and/or the recipient.

• Having a patient return to the office for additional visits that are not necessary.

• Taking unnecessary x-rays, blood work, etc.

• Upcoding, e.g., Seeing a patient for 15 minutes but billing for a 60 minute visit.

• Using an unlicensed person to perform services of a licensed professional, and then billing as if a licensed professional provided the service.

• Billing for more time than actually provided, i.e., counseling, anesthesia, etc.

• Billing for an office visit when there was none, or adding additional family members' names to bills.

• Accepting payment from another provider, including sharing in the reimbursement paid by the Medicaid program, as a result of referring a patient to the other provider.

Report Provider Fraud

To file a complaint, Click Here. 

Request Report on Provider (For use by Medicaid Programs only)

To request SURS Report, Click Here.