Who We Are

Program Integrity (PI) of the N.C. Division of Medical Assistance (DMA) has seven sections (104 employees) devoted to accountability of how the public's money is spent for Medicaid services in N.C.

• Program Integrity Sections
• Program Integrity Mission

Money Recovered From Program Integrity Investigations

Efforts of the staff in Program Integrity saved, recover, or avoided N.C. Medicaid costs of more than $1.1 billion during Stae Fiscal Year (SFY) 2006.

More detailed Program Integrity data - Medicaid Annual Reports.

Fraud and Abuse Investigations

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.

Criminal Fraud Prosecution

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.

Public Concern over Fruad, Waste, and Abuse in Health Care

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.

Updated July 11, 2008