Honor. Performance. Integrity. The Office of Inspector General (OIG) safeguards the integrity of the Georgia Department of Community Health (DCH) from risk internally and externally. Detecting fraud, waste and abuse is the office’s clear charge.
The OIG rigorously reviews, investigates and audits Medicaid providers and recipients to uncover criminal conduct, administrative wrongdoing, poor management practices, and other waste, fraud and abuse. OIG also reviews the State Health Benefit Plan (SHBP), Healthcare Facility Regulation and other offices at DCH.
Additionally, the office provides department oversight, audit and Third Party Liability (TPL) services. The office has seven units:
- Medicaid/PeachCare For Kids® Program Integrity Unit -- The Medicaid/PeachCare For Kids® Program Integrity Unit performs utilization reviews and investigates providers suspected of overbilling or defrauding Georgia’s Medicaid program. The Unit recovers overpayments, and where appropriate, refers cases of suspected fraud for criminal investigation and prosecution to federal, state and local officials. In FY 2016, approximately $39.4 million in overpayments, settlements, and fines were recovered, an increase of 45% from FY 2015. For FY 2017, approximately $116.7 million has been recovered.
- Special Investigations Unit-- Examines allegations of fraud, waste and abuse by DCH employees, contractors, sub-contractors and vendors
- Office of Audits -- The Office of Audits performs independent, objective assurance and consulting actions intended to enhance the Department’s operations to ensure compliance with State and Federal regulations in all areas of performance, including procedural and financial activities. The office conducts audits and/or reviews as part of their yearly Audit Plan.
- Third-Party Liability Unit -- The Third-Party Liability Unit is responsible for identifying Medicaid beneficiaries who are dually-covered by Medicaid and another medical insurance plan. Those other plans are legally responsible for paying the beneficiaries’ claims, and when necessary, ensuring that the Medicaid program is the payer of last resort by pursuing this liable third-party for reimbursement. In FY 2016, the Unit recovered approximately $40.3 million from responsible third parties.
- Background Investigations Unit -- The Background Investigations Unit performs state and federal criminal history background investigations and credit checks on behalf of the Department, including the Office of Health Care Facility Regulation and the Office of Human Resources It is also responsible for the proper access, maintenance, storage, and use of all criminal history record information obtained by the Department in partnership with the Georgia Crime Information Center.
- Data Integrity and Analysis Unit -- The Data Integrity and Analysis Unit is responsible for using data analytics and predictive modeling in the detection of fraud, waste and abuse, including identification of patterns of suspicious behavior or billing anomalies. Additionally, the Unit monitors OIG related information and reports from the Medicaid Management Information System to identify and correct inaccuracies and in so doing ensures data integrity.
- OIG Legal/State Health Benefit Plan Fraud Unit -- The Legal/State Health Benefit Plan (SHBP) Unit provides advice and representation for the Division on all legal matters and is responsible for coordinating inquiries related to allegations of fraud, waste and abuse within the SHBP’s three plans: the State Employees Plan, the Teachers Plan, and the Public School Employees Plan. The Unit also represents the OIG at administrative hearings in Program Integrity cases in which providers have filed appeals concerning overpayments.
Any DCH employee or private citizen may report fraud, waste and abuse.
Office of Inspector General
ATTN: Special Investigations Unit
2 Peachtree Street, NW 5th Floor
Atlanta, GA 30303
404-463-7590 • 800-533-0686
E-mail: email@example.com or ReportMedicaidFraud@dch.ga.gov.
Submit online form.