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Program Integrity for Providers in Managed Care

This presentation by Patrick Piggott, MSW, LCSW, DCSW, focuses on the vital role of Program Integrity (PI) within North Carolina's Medicaid landscape. Participants will learn about the responsibilities of the Behavioral Health Review Section (BHRS), including post-payment reviews and the referral of credible fraud allegations. With approximately 1.8 million Medicaid recipients across all 100 counties, effective partnerships and oversight are essential in combating fraud, waste, and abuse. Engage in discussions about data-driven investigations and analytics that support the integrity of managed care programs.

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Program Integrity for Providers in Managed Care

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  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@dhhs.nc.gov Website: http://www.ncdhhs.gov/dma

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