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Medicaid Program Integrity: Ensuring Proper Utilization of Healthcare Funds

This program ensures Medicaid funds are spent appropriately through comprehensive utilization reviews to prevent fraud, waste, and abuse. Common mistakes are identified and corrected to protect program integrity. Contact Elizabeth Brooks for more information.

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Medicaid Program Integrity: Ensuring Proper Utilization of Healthcare Funds

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  1. PROGRAM INTEGRITY Elizabeth Brooks Office of the Inspector General Date: 8/21/2018

  2. Mission: The mission of the Department of Community Health is to provide access to affordable, quality health care to Georgians through effective planning, purchasing, and oversight.

  3. Purpose: Shaping the future of A Healthy Georgia by improving access and ensuring quality to strengthen the communities we serve.

  4. Program Integrity’s Purpose Ensure that Medicaid dollars are being used appropriately. Title or Chapter Slide (use as needed; feel free to delete)

  5. Utilization Reviews • Purpose of these reviews is to ensure that Medicaid dollars are being spent appropriately • Reviews are conducted by both DCH internal staff/vendors • All reviews are based on DCH policy, state and federal laws, if applicable

  6. Utilization Reviews Cont. • Reviews can be done in person or medical records can be requested • Reviews are looking for compliance with DCH policy while ensuring that there is no fraud, waste or abuse

  7. Abuse • Abuse - Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care. It also includes beneficiary practices that result in unnecessary cost to the Medicaid program

  8. Waste • Waste - overutilization of services that cause unnecessary expenses.

  9. Fraud • Fraud – is an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law

  10. Common Mistakes • Care Plan – Expired, doesn’t cover the whole review period or missing from member’s file • Services Record Form – The tasks are not properly documented, missing signatures of both the aide and member or member’s representative, no time in and/or time out documented • Supervisory Visits – late/missed

  11. Common Mistakes Cont. • Provider Care Plan is not being updated appropriately after the supervisory visits (quality of care issue) • Using the wrong code for PSS and PSSX services • Documentation doesn’t support the number of hours billed • Staff signatures missing from Service Record Form and/or progress notes

  12. Contact information • My contact information is ebrooks@dch.ga.gov or 404-463-7437 • Johnny’s contact information is Johnny.Brooks@dch.ga.gov or 404-463-7144

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