• Provider Medical Review Section (PMRS)
• Home Care Review Section (HCRS)
• Pharmacy Review Section (PRS)
• Provider Administration Review Section (PARS)
• Third Party Recovery Section (TPR)
• Quality Assurance Section (QA)
• Special Projects Section (SPS)

Provider Medical Review Section

The Provider Medical Review section (supervisor nurse, eleven registered nurses, one licensed clinical social worker, and two support staff) 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: Carleen Massey at (919) 647-8000
Fax: 715-7705
Email at Carleen.Massey@ncmail.net

Home Care Review Section

The Home Care Review Section includes one nurse supervisor and 9 additional registered nurse analysts, one support staff member and one staff member for complaint call intake. This section conducts post payment reviews on home and community based services provided to Medicaid recipients to determine of 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, 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 from the Home Care Review section also conduct 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: Carol Putnam (919) 647-8032
Fax: (919) 647-8055
Email at carol.putnam@ncmail.net

Pharmacy Review Section

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: Ann Slade at (919) 647-8000
Fax: 715-7706
Email at Ann.Slade@ncmail.net

Provider Administrative Review Section (PARS)

The Provider Administrative Review Section (PARS) includes the supervisor, one Dental Hygienist, five investigators, one Operations Analyst, and two support staff.

PARS Investigative/Operations staff perform post-payment administrative reviews of provider (except Pharmacy) claims and services to determine the appropriateness of claim submission practices and verify providers' compliance with Medicaid coverage, billing policies and Provider Participation Agreements/contracts. Administrative reviews involve examination of claims/payment data, medical record documentation, and research and application of Medicaid coverage policy. Post payment reviews of Dental Providers include review of clinical services to determine if the services were medically necessary and were of acceptable quality. Reviews of patient personal fund issues by the Operations Analyst assure that Medicaid recipients residing in nursing facilities are not incorrectly billed for Medicaid covered services.

Contact: (919) 647-8000
Fax: (919) 647-8054
Email at Pat.Delbridge@ncmail.net

Third-Party Recovery Section and System Support Section (TPR)

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:

• Casualty Investigations: recovers Medicaid payments from other insurers due to accidental injuries, and product or medical negligence
• Post Payment: ensures that credit balances owed by providers are reimbursed to the program and oversees Credit Balance Reviews; implements the Medicaid Estate Recovery Plan; and processes Medical Support Payments (IV-D); the Health Insurance Premium Payment (HIPP) prgram; and Medicare overpayments
• Cost Avoidance: updates recipient files with third party insurance; recovers prescription drug payments; oversees the TPL contract
• Systems Support: develops queries to the Medicaid claim data warehouse (DRIVE) to support provider investigations; performs ad hoc reports of provider activities to identify areas of abuse and/or fraud; assists in maintaining the Fraud and Abuse Detection system; provides programming for TPR to use automation in place of manual processes to expedite recovery of money; collects data and provides reports of Program Integrity activities.

More Third Party Information

• Third Party Insurance Codes
• Third Party Insurance Forms
• Basic Medicaid Billing Guide

Contact:  (919) 647-8100
Fax: 715-4725
Email at Marilyn.Vail@ncmail.net

Quality Assurance Section

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. 

• The Medicaid Eligibility Payment Error Rate section monitors the accuracy rate of eligibility determinations in the 100 county DSS's by conducting both federally mandated and state-designed targeted reviews of recipient cases. The case reviews are conducted by staff assigned and living near certain counties. The results of their reviews are used to determine error trends, identify error prone cases, and recommend corrective action as appropriate. QA data is also used to assist county supervisors and state staff in determining training needs to prevent future errors. The staff also conducts additional Corrective Action Record Reviews for each county to identify potential problem areas in the procedural process of determining eligibility.
• The Recipient Fraud section has two policy consultants dedicated to the coordination of investigations by county Program Integrity staff of suspected recipient Medicaid fraud and abuse The consultants provide Fraud and Abuse policy, and training on prevention, detection, and recovery of Medicaid overpayments to county staff. They also provide policy for the EPICS data system, used to track all benefits overpayment collections.
• The Recipient Complains section also investigates Medicaid claims when the provider has billed Medicaid, and also billed the recipient. The claims investigator serves as a mediator between the recipient and the provider to identify and resolve inappropriate billing issues. If a provider is at fault and unwilling to comply with Medicaid billing requirements, a referral may be made to the Attorney General's office.

Quality Assurance
Phone: 919-647-8100
Fax: 919-715-7706

Special Projects Section

The Special Projects Section oversees the Fraud and Abuse Detection System (FADS) and payment accuracy measurement activities.

The Fraud and Abuse Detection System (FADS) consists of two software applications:

• HealthSPOTLIGHT uses data modeling techniques to compare provider billings and also has specific fraud detection filters.
• OmniAlert is used to identify aberrant billing patterns among provider peer groups.

These software applications identify suspicious claims or patterns of services by providers for further investigation. This sofware is also shared with the Attorney General's Medicaid Investigations Unit.

Payment Accuracy Measurement:

The unit conducts two separate sets of claim reviews to determine the accuracy rate for providers billing 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.

• Office of State Auditor Sample:

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.

• Payment Error Rate Measurement (PERM):

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). North Carolina has been selected as one of 17 states required to participate in PERM review for Federal fiscal year 2007 (October 1, 2006 - September 30, 2007).

CMS is using three national contractors to measure improper payments: a statistical contractor; a documentation/database contractor, and a review contractor. These contractors will be working with selected states to evaluate the accuracy of each state's error rate. Therefore, it is important that state's and their respective Medicaid and SCHIP providers provide information that is requested by the contractors in a timely and complete manner. No response to requests and/or insufficient documentation will be considered a payment error. This can result in a payback by the provider and a monetary penalty for North Carolina Medicaid.

The Special Projects Section will be coordinating PERM activities with its internal and external stakeholders.

(919) 647-8000
Fax: 647-8054

Updated July 11, 2008