Given Governor Brian P. Kemp’s Executive Order 06.22.21.01, effective July 1, 2021, DCH will resume utilization reviews and onsite investigations beginning July 1, 2021.
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.
The office has six units:
- Program Integrity Unit -- The Program Integrity Unit performs utilization reviews on claims and investigates suspected fraud, waste, and abuse of Georgia’s Medicaid/PeachCare for Kids programs®. The Program Integrity Unit is comprised of three sub-units: Intake and Analytics, Review and Investigations, and Pharmacy Lock-in.
- Intake and Data Analytics sub-unit: The Intake and Data Analytics sub-unit is responsible for the fraud hotline, which provides an anonymous and confidential whistleblower reporting service for potential Medicaid fraud. In addition, the sub-unit detects patterns of fraud, waste, and abuse utilizing data analysis.
- Review and Investigations sub-unit: The Review and Investigations sub-unit is responsible for reviewing claims for payment discrepancies inconsistent with Medicaid/PeachCare for Kids and waiver program policies. The unit also investigates credible allegations of fraudulent activity related to Medicaid/PeachCare for Kids programs.
- Pharmacy Lock-In sub-unit- The Pharmacy Lock sub-unit is responsible for identifying unnecessary or overutilization of pharmacy services for Medicaid/PeachCare for Kids programs.
- Special Investigations Unit-- This unit is charged with investigating employee misconduct involving Standards of Conduct, Ethics, and Conflict of Interest policy violations and fraud, waste, and abuse involving employees, contractors, and vendors. The unit also investigates members who receive services they are not entitled to such as allowing unauthorized individuals to use their Medicaid card.
- 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, including operational and financial activities.
- 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.
- 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 Healthcare Facility Regulation and the Office of Human Resources.
- OIG Legal Unit -- The OIG Legal Unit provides advice and representation for the division on all legal matters.
This strategic plan represents a considerable effort undertaken by the Office of Inspector General leadership team to focus and identify the strengths, opportunities, and challenges of the programs delivered to the citizens of Georgia. Over the next five years, the department will prioritize, draft and implement strategies that will create defined organizational goals, performance measures, and goal initiatives.