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Self-Disclosure

The Department of Community Health encourages providers to be active participants in ensuring the financial integrity of our healthcare programs.   Providers are urged to self-audit in an effort to identify claims errors and overpayments.  Upon identifying a claims error or overpayment, providers must alert the Department and work toward a resolution or refund. 

Self reporting offers providers the opportunity to minimize the potential cost and disruption of a full scale audit and investigation and to negotiate a fair monetary settlement.  Please note that self disclosure will not absolve the provider of criminal culpability. If the Medicaid Fraud Control Unit or any other federal, state, or local agency determines a crime was committed, any information shared with the Department will be forwarded to the appropriate agency.

Once a provider has identified claims that are potential overpayments, a self disclosure letter detailing the potential overpayments should be forwarded to the Program Integrity Unit within the Office of Inspector General. Any self disclosure submitted to the Department for consideration must include the information outlined in Part I Policies and Procedures for Medicaid/PeachCare for Kids, Chapter 400, Section 402.10.   

The Department reserves the right to verify the financial impact of the disclosed matter utilizing its internal auditing procedures. Accordingly, the Department expects to receive documents and information from the entity that relate to the disclosed matter without the need to resort to compulsory methods. Self disclosed matters are not subject to appeal rights as outlined in Part I, Policies and Procedures forMedicaid/PeachCare for Kids Manual Chapter 500. Matters uncovered during the verification process which are outside of the scope of the self disclosure may be treated as new matters subject to further investigation and possible adverse action.

Upon receipt of the self-disclosure letter and Corrective Action Plan (CAP), the Program Integrity Unit will verify the accuracy of the information. The Unit will also approve the CAP or suggest revisions. Once a final determination of accuracy is completed and the CAP is approved, the Department will enter into negotiations with the provider regarding a settlement. As a mandatory provision of the settlement agreement, the Department will require an audit of the provider within a 12 month period to assure adherence to the CAP.