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Adverse Actions

When PI uncovers improper utilization of Medicaid benefits, we employ several methods of identifying fraud, waste, and abuse and recovering improper payments. The following are descriptions of some methods we utilize to minimize improper reimbursement and recover improperly reimbursed funds:

• Prepayment Review (PPR):PI’s contracted vendor GMCF reviews claims submitted by providers on PPR.  These claims are required to include hard copy documentation of all services under review for reimbursement. Providers that demonstrate a pattern of aberrant billing practices are placed on PPR for a six (6) month period to a year.   If the provider demonstrates that they are in compliance with billing guidelines, and irregularities cease to exist, PI may rescind the PPR.
  
  
• Reimbursement Withhold: This is the process of withholding reimbursement funds from providers whether or not a demand has been made for repayment, for several reasons which are defined in our policy manuals. PI has been granted this authority in the C.F.R. SAFKDSMFL,.SD.,M.,
   
• Recoupment: Improper payments are recouped from providers that are identified through onsite and medical record reviews if the provider does not provide adequate documentation to substantiate the claims billed and after the provider has exhausted the Administrative Review Process as defined in Part I Policies and Procedures for Medicaid and PeachCare for Kids.

A complete list of all DMA policy and procedure manuals can be found on the Georgia Health Partnership website located at www.ghp.ga.gov in the Provider Section. The policies addressing the Department of Community Health requirements are included in DMA’s Part I, Policies and Procedures for Medicaid/PeachCare for Kids and the applicable DMA Part II, Policies and Procedures for the type of provider services being rendered, i.e. Physician Services, Dental Services, Certified Nurse Midwife Services, etc.

Authority: State Plan; Title XIX, Social Security Act, 42 C.F.R. Parts 431, 455, 456, 1000, 1001, 1002, State Medicaid Manual 11420.6M. Rule effective October 1, 1982.
Amended November 10, 1988. Effective date of this amendment March 15, 1994.
Rule No. 560-X-4-.03. Method.

Authority: State Plan; Title XIX, Social Security Act, 42 C.F.R. Parts 401, 431, 455,456, State Medicaid Manual 11420.6M. Rule effective October 1, 1982. Amended December 10, 1987; November 10, 1988; March 15, 1994; and March 26, 1996. Effective date of this amendment June 11, 1996. Rule No. 560-X-4-.05. Abuse, Fraud, and/or Deliberate Misuse by Recipients or Sponsors of Recipients.