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Medicaid Fraud and Abuse Confidential Online Complaint Form
How to Report Fraud and Abuse Information for Consumers
Fraud and Abuse Information for Providers
Clarence Ervin, Assistant Director
Phone: 919-647-8000
Fax: 919-647-8054
Program Integrity (PI) is devoted to ensuring that Medicaid payments are accurate and that fraud, waste, or program abuse are identified and prevented.
Efforts of the staff in Program Integrity saved, recovered, or avoided N.C. Medicaid costs of more than $1.1 billion during State Fiscal Year (SFY) 2006.
More detailed Program Integrity data - Medicaid Annual Reports.
Program Integrity is committed to identifying Medicaid overpayments and fraud. We actively pursue any leads indicating fraudulent practices and use them as a source to begin investigations. To increase our effectiveness, we have partnered with the Medicare carriers and Federal staff to share information about fraudulent activity and conduct joint investigations.
Program Integrity receives complaints from patients, their families, other providers, former employees of a provider, and through federal and state referrals. Program Integrity staff investigates every complaint. In addition, we also identify patterns of fraud and abuse through our Fraud and Abuse Detection System (FADS),
Review decisions can result in refunds to the program for inappropriate Medicaid payments, training on how to correct or improve billing practices, referral to licensing boards, and/or referral to the N.C. Office of the Attorney General for suspected fraudulent practices.
Program Integrity also targets areas with a high-risk potential for abuse. We submit suggestions for improvement to DMA Management who then work with the provider associations to find solutions.
While Program Integrity identifies Medicaid fraud, the Attorney General's Medicaid Investigations Unit (MIU) takes the legal action to convict a provider of criminal fraud. The MIU coordinates their efforts with the IRS, State Bureau of Investigation, FBI, Drug Enforcement Agency, U.S. Attorney, Office of Inspector General and the Medicaid Fraud Control Units in other states to resolve fraud cases. As a general rule, once a case is taken by the MIU, Program Integrity staff involvement with the provider ceases.
Health care costs are increasing every year. The available money to fund Medicaid and other State programs is decreasing. Fraud and abuse takes money from needy children, the elderly, blind, and disabled. Therefore, identifying, investigating, preventing and recovering money billed improperly to Medicaid is an important mission for this agency.
The majority of providers and their billings are honest and accurate. However, one dishonest provider can take thousands of dollars slowly over time by billing for services not rendered or medically unnecessary. Far worse, with computerized electronic billing, one dishonest provider can illegally take hundreds of thousands of dollars in a few weeks or months. These occurrences often provide a negative perception of the overall program.
While many PI reviews are targeted at specific complaints or suspicions, often our reviews are routine. Our review process is not intended to impugn the integrity of any provider or category of care but merely to verify the accuracy of the need, provision, and payment for the services provided. We attempt to make every routine review as convenient as possible and work with the provider to reduce the distraction that might occur.
It is the mission of Program Integrity to ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupments, and identifying avenues for cost avoidance.
Program Integrity, through teamwork with our DMA partners,
To report suspected improper Medicaid billing, program abuse, waste or fraud, refer to Reporting Fraud and Abuse or contact us directly using the e-mail addresses and telephone numbers listed below for the Program Integrity sections.
Contact: Geneva Fearrington
Phone:
919-647-8000
Fax: 715-7705
Email at Geneva.Fearrington@dhhs.nc.gov
The Provider Medical Review Section (PMRS) includes one registered nurse supervisor, eight registered nurses, three investigators, and one administrative support staff member. PMRS performs post payment review of services to determine if the services were medically necessary, were of acceptable quality, and conform to Medicaid coverage and billing policies.
Reviews are performed primarily on physicians and hospitals, but also on other provider types to whom Medicaid makes payments such as ambulance, optometrists, podiatrists, and rural health clinics.
Reviews are initiated from automated reports, referrals from licensing and social service agencies, and complaints from recipients and the general public. Reviews involve examination of claims/payment data, medical record documentation, and research and application of Medicaid coverage policy.
Contact: Carol Putnam
Phone: 919-647-8000
Fax: 919-647-8055
Email at Carol.Putnam@dhhs.nc.gov
The Home Care Review Section includes one nurse supervisor, nine additional registered nurse analysts, one dental investigator, two administrative investigators, and one administrative support staff member. This section conducts post payment reviews on dental and home and community based services provided to Medicaid recipients to determine if the services were medically necessary, of acceptable quality and if they were provided in accordance with Medicaid coverage and billing policies. In addition, the analysts review for evidence that the provider is practicing in accordance with the terms and conditions of Medicaid participation and claims submission agreements. The provider types reviewed include, but are not limited to: Home Health and Hospice, Dentists, Durable Medical Equipment, Private Duty Nursing, Personal Care Services, Independent Practitioners, Community Alternatives Program (CAP) for Disabled Adults and for Children, and Adult Care Homes.
Reviews are initiated from automated reports, referrals from licensing and other regulatory or state agencies, complaints from recipients, CMS contractors, other sections within DMA and the general public. Reviews involve examination of claims/payment data, medical record documentation, and research and application of Medicaid coverage policy. Analysts and investigators from the Home Care Review section also conduct both announced and unannounced provider office site visits and recipient interviews.
If overpayments are noted as a result of a post payment review, the Home Care Review Section attempts to recover inappropriately spent Medicaid dollars and educate providers regarding the identified errors in policy compliance or billing. Apparent fraudulent practices are referred to the Attorney General’s Medicaid Investigations Unit. The staff within this section works collaboratively with and supports the staff from the Medicaid Investigations Unit in the investigative process.
Contact: Ann Slade
Phone: 919-647-8000
Fax: 715-7706
Email at Ann.Slade@dhhs.nc.gov
The Pharmacy Review Section includes one pharmacist Section Chief, three staff pharmacists, five pharmacy investigators, and two support staff. This section performs post-payment reviews of Medicaid pharmacy claims through desk audits and routine or targeted on-site audits. They recover overpayments, resolve pharmacy complaint calls and educate providers regarding Pharmacy policy and/or problem areas. This section also provides support and resources to Attorney General's Medicaid Investigations Unit.
Contact: Patrick Piggott
Phone: 919-647-8000
Fax: 919-647-8054
Email at Patrick.Piggott@dhhs.nc.gov
The Behavioral Health Review Section (BHRS) includes one Program Manager as Section Chief, one Lead Nurse Analyst, two Nurse Analysts, two Program Coordinators (East and West Region), three Behavioral Health Investigators, two LCSW Analysts, and one support staff.
BHRS staff performs post-payment administrative and clinical reviews of behavioral health provider claims and services to determine if the services were medically/clinically appropriate and verify behavioral health providers' compliance with Medicaid coverage, billing policies, and Provider Participation Agreements/contracts. Reviews involve examination of claims/payment data, medical record documentation, financial records, and research and application of Medicaid coverage policies. Behavioral health provider reviews are conducted at on-site and off-site locations.
BHRS conducts preliminary reviews on all cases referred by recipients; providers; licensing boards and association; and local, state, and federal agencies.
Contact: Mack Nance
919-647-8100
Fax: 919-715-4725
Email at Mack.Nance@dhhs.nc.gov
The Third-Party Recovery Section and System Support Section (TPR) is primarily responsible for the recovery of Medicaid payments for services that should have been paid by health insurance plans and liability insurance. TPR is also responsible to ensure that accurate insurance information is on recipient files before Medicaid pays claims. Last year, the TPR Section recovered $56,575,910 and saved over $400 million through cost avoidance.
The TPR Section has 34 employees within the following units:
More Third Party Information
Contact: Jeryl Anderson
Phone: 919-647-8000
Fax: 919-715-7706
Email at Jeryl.Anderson@dhhs.nc.gov
The Quality Assurance Section supervisor has 21 staff. Their mission includes determining the Medicaid and Health Choice (the new children's health insurance program) eligibility payment error rates and assisting in correcting problems. They also coordinate the recipient fraud investigations with the counties and handle recipient complaints and investigations of overcharging for Medicaid covered services.
Contact: Peggy Scott
Phone: 919-647-8000
Fax: 919-647-8054
Email at Peggy.Scott@dhhs.nc.gov
The Special Projects Section (SPS) has ten employees within the following two units:
Listed below are two significant claim reviews to determine payment accuracy for providers billing N.C. Medicaid. Both involve selecting a stratified random sample of paid claims, obtaining supporting medical record documentation from the provider, conducting process and medical record reviews of the paid claims, and following up on any identified problems.
This section reviews a 12-month sample of paid claims pulled by the Office of State Auditor who uses the resulting error rate to comply with the State's CAFR.
In compliance with the Improper Payments Information Act of 2002, the Centers for Medicare and Medicaid Services (CMS) implemented a national Payment Error Rate Measurement (PERM) program to measure improper payments in the Medicaid program and the State Children's Health Insurance Program (SCHIP). The PERM review is mandatory across all 50 states. N.C. Medicaid is one of 17 states scheduled for the upcoming FFY 2010 review. PERM errors result in a recoupment for the claim to the provider and a monetary penalty for N.C. Medicaid.
The Special Projects Section coordinates PERM activities with its internal and external stakeholders, monitors the national websites for errors, provides detailed explanations to the review contractor, providers error dispute information to the review contractor, appeals decisions to CMS if necessary, and coordinates the corrective action plan for PERM. More PERM Information for Providers
