Fraud and Abuse
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Fraud And Abuse Hotline To report anonymously by email |
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WHO WE ARE
As part of the General Counsel Division in Georgia’s Department of Community Health, the Program Integrity Unit identifies and pursues individuals and providers misusing or abusing the State Health Benefit Plan. Our primary goal is to identify and respond to fraud and abuse within the system, and assist providers with education and corrective action.
We:
- Use the latest technology to detect and correct abuse and identify fraud;
- Maintain strong relationships with other state and federal agencies which also identify and prosecute fraud and abuse;
- Keep the lines of communication open with professional medical organizations to more easily identify providers who abuse the State Health Benefit Plan. We also coordinate efforts with our counterparts in the Southeast;
- Have developed a centralized information system that tracks cases from beginning to end;
- Strive for cost avoidance with corrective action, education, and prevention.
The Program Integrity unit is focusing its efforts on the enforcement of policy and the verification of recipient eligibility.
WHY WE EXIST
Each dollar lost to theft or abuse is one less available for someone who really needs care. By stopping fraud and abuse, and concentrating on cost avoidance, we help save tax dollars and ensure that valuable healthcare services will be available for eligible members in the future.
DEFINITION OF FRAUD
Fraud is an intentional deception or misrepresentation made by a person with the knowledge that it could result in some unauthorized benefit for himself or others. It includes any act that constitutes fraud under applicable federal or state law.
DEFINITION OF ABUSE
Abuse includes provider practices that are inconsistent with sound fiscal, business or medical practices, which result in unnecessary costs to the State Health Benefit Plan program, or in reimbursement of services that are not medically necessary or that fail to meet professionally recognized standards for health care. Member practices that result in unnecessary costs to the State Health Benefit Plan are also considered abuse.
TYPES OF FRAUD AND ABUSE
Examples of cases of fraud and abuse that the unit investigates include unreported income or insurance, Georgia members living out of state, drug-seeking behavior, incarceration, individuals receiving bills (or EOB statements) for services never provided, provider billing irregularities, and over or under use of health care services, and misrepresentation of credentials. Provider fraud could involve doctors, hospitals, nursing homes, home health, durable medical equipment, pharmacies, mental health facilities, laboratories, transportation and dentists. This list is not exhaustive.
WHAT IS IN IT FOR YOU?
The Program Integrity Unit, along with the Georgia Bureau of Investigation, Medicaid Fraud Control unit, Office of Inspector General, Federal Bureau of Investigation, Attorney General's Office, Department of Human Services, the State Health Benefit Plan and many other state and federal offices have recovered millions of health dollars. We provide our expertise, consultation and staff to all departments to help combat fraud, abuse, and waste within Georgia.