Program Integrity for Providersin Managed Care

Patrick Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review Section

OBJECTIVES

ObjectivesAt the completion of this presentation participants will be able to:

• Describe role DMA Program Integrity (PI)

• List one responsibility of the Behavioral Health Review Section (BHRS)

• Identify partnerships in combating fraud, waste, and abuse

Medicaid Landscape

• Approximately 1.8 million Medicaid recipients

• Recipients in all 100 North Carolina counties

• 9 Behavioral Health Prepaid Inpatient Health Plans (PIHP) also known as Local Management Entities –Managed Care Organizations (LME-MCO)

• Under 3 year old population not covered by managed care

Role of Program Integrity

Role of Program Integrity

• Ensure compliance, efficiency, and accountability within the N.C. Medicaid

• Ensure that Medicaid dollars are paid appropriately

Responsibilities of BHRS

• Perform post-payment reviews of MH/DD/SA providers.

• Conduct preliminary investigations on all complaints

Responsibilities of BHRS

• Oversight and Monitoring of 9 PIHP program integrity activities

• Collaborate and/or coordinate with State agencies

Responsibilities of BHRS All cases of credible allegations of fraud are referred to the Medicaid Investigation Division (MID).

PI-MID-PIHP meet quarterly to discuss program integrity-related activities in Managed Care.

Partners

• Technology

• Prepayment Review

• Post-payment Review

• Investigations and Oversight

Reporting and Analytics

Reporting and Analytics

Audits and investigations are driven by data analytics and reporting systems associated with behavioral health providers.

WHAT ARE YOUR QUESTIONS

ContactPatrick Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review SectionNC Division of Medical AssistanceProgram Integrity Phone: 919-814-0143 Fax: 919-814-0035Email at [email protected] Website: http://www.ncdhhs.gov/dma