Program Integrity
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Fraud And Abuse Hotline To report anonymously by email click here now. |
PI which is led by Shirley Benson, RN, is charged with the responsibility of monitoring the utilization habits and patterns of both members and providers of the Medicaid Community. PI consists of five teams including: Hospital, Pharmacy, Physician Services, Waivers and Professional Services.
The PI Section covers the entire state of
Patterns of Fraud and Abuse by providers can include but are not limited to:
- Filing claims for a higher level service than was actually performed. Also referred to as "up-coding"
- Billing for services before service is actually rendered
- Altering claim forms and patient records
- Billing for non-covered services
- Performing services that are not medically necessary
- Submitting claims for services that were rendered by a physician that is not a Medicaid provider
- Billing a member for covered services
- Seeking reimbursement from a member for claims denied, reduced or recouped by the department
Patterns of Fraud and Abuse by members can include but are not limited to:
- Drug overutilization or overutilization of services
- Criminal activity involved in securing medical services (such as forged prescriptions
- Repeated failure to safeguard the Medicaid card
- Collusion with providers for services or supplies
- Providing incorrect information or allowing others to do so in order to obtain Medicaid eligibility
- Failure to report changes which occur in income, living arrangements, or resources
Purpose
The purpose of the Program Integrity Section is to guard against fraud, abuse, and deliberate waste of Medicaid program benefits. PI accomplishes this by scrutinizing complaints from the Medicaid Fraud & Abuse Hotline which can be reached by calling (404) 463-7590 or toll free at (800) 533-0686, by US Mail at
Department of Community Health
OIG PI Section
Complaints are also received from various other State and Federal agencies. Callers can remain anonymous when reporting suspected program misuse or abuse.
Program Integrity seeks to ensure that
Medicaid Surveillance and Utilization Review (SUR) and Pharmacy Audits
The PI SUR teams generate profiles based on billed claims, and utilization patterns of Medicaid providers and members that are based on user-defined parameters and other criteria. By analyzing and comparing providers to their respective peer groups, abnormal patterns of practice can be identified. Appropriate action can then be initiated to substantiate the data patterns identified during the SUR review.
SUR staff members identify aberrant behaviors, conduct hospital, physician and other provider type audits to educate providers on program guidelines, and recover inappropriately reimbursed funds.
When potential patterns of over utilization, fraud or abuse are received or identified, PI uses several methods to substantiate this information, including but not limited to:
- Onsite visits to provider locations
- Member surveys to verify services were rendered
- Claims analysis for members and providers
- Peer comparisons
- Medical Records reviews
PI works jointly with a variety of regulatory agencies that include but are not limited to the Medicaid Fraud Control Unit (MFCU), Medicare Program Safeguard Contractors, and the GBI.