The Medicaid 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.
The Special Investigations Unit upholds the best interest and confidence of the public by ensuring that Department policy and procedures are followed and that all Department employees, including contractors, sub-contractors and vendors adhere to Department standards of professionalism. The Unit’s charge includes conducting objective and independent investigations involving alleged violations of Standards of Conduct, Ethics and Conflict of Interest policy and claims of fraud, waste and abuse. The Unit also conducts Medicaid provider and recipient investigations and makes referrals to the Medicaid Fraud Control Unit for possible criminal investigation.
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.