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Program Integrity for Providers in Managed Care

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Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section OBJECTIVES Objectives At the completion of ... – PowerPoint PPT presentation

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Title: Program Integrity for Providers in Managed Care


1
Program Integrity for Providersin Managed Care
  • Patrick Piggott, MSW, LCSW, DCSW
  • Chief, Behavioral Health Review Section

2
OBJECTIVES
3
Objectives
  • At 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

4
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

5
Role of Program Integrity
6
Role of Program Integrity
  • Ensure compliance, efficiency, and accountability
    within the N.C. Medicaid
  • Ensure that Medicaid dollars are paid
    appropriately

7
Responsibilities of BHRS
  • Perform post-payment reviews of MH/DD/SA
    providers.
  • Conduct preliminary investigations on all
    complaints

8
Responsibilities of BHRS
  • Oversight and Monitoring of 9 PIHP program
    integrity activities
  • Collaborate and/or coordinate with State agencies

9
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.

10
Partners
  • Technology
  • Prepayment Review
  • Post-payment Review
  • Investigations and Oversight

11
Reporting and Analytics
12
Reporting and Analytics
  • Audits and investigations are driven by data
    analytics and reporting systems associated with
    behavioral health providers.

13
  • WHAT ARE YOUR QUESTIONS

14
Contact
  • Patrick Piggott, MSW, LCSW, DCSW
  • Chief, Behavioral Health Review Section
  • NC Division of Medical Assistance
  • Program Integrity Phone 919-814-0143 Fax
    919-814-0035Email at Patrick.Piggott_at_dhhs.nc.gov
  • Website http//www.ncdhhs.gov/dma
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