Office of Inspector General

Office of Inspector General
Overview
The Office of the Inspector General (OIG) is committed to protecting the taxpayers of Georgia by detecting, preventing and/or eliminating all forms of fraud, waste and abuse associated with the operation of the Medicaid Program.
Division Sections
The OIG oversees:
Program Integrity Unit
The Program Integrity Unit performs utilization reviews on claims and investigates suspected fraud, waste, and abuse of Georgia's Medicaid/PeachCare for Kids programs. The Program Integrity Unit is comprised of three sub-units: Intake and Analytics, Review and Investigations, and Pharmacy Lock-in.
Intake and Data Analytics sub-unit: The Intake and Data Analytics sub-unit is responsible for the fraud hotline, which provides an anonymous and confidential whistleblower reporting service for potential Medicaid fraud. In addition, the sub-unit detects patterns of fraud, waste, and abuse utilizing data analysis.
Review and Investigations sub-unit: The Review and Investigations sub-unit is responsible for reviewing claims for payment discrepancies inconsistent with Medicaid/PeachCare for Kids and waiver program policies. The unit also investigates credible allegations of fraudulent activity related to Medicaid/PeachCare for Kids programs.
Pharmacy Lock-In sub-unit- The Pharmacy Lock sub-unit is responsible for identifying unnecessary or overutilization of pharmacy services for Medicaid/PeachCare for Kids programs.
The Special Investigations Unit
The Special Investigations Unit upholds the best interest and confidence of the public by ensuring that department policy and procedures are followed and that all department employees, including contractors and vendors, adhere to department standards of professionalism. The unit's charge includes conducting objective and independent investigations involving alleged violations of Standards of Conduct, Ethics and Conflict of Interest policy and claims of fraud, waste and abuse. The unit also conducts investigations of Medicaid members and providers relating to eligibility and fraud, respectively.
The Office of Audits
The Office of Audits performs independent, objective assurance and consulting activities intended to enhance the department's operations to ensure compliance with State and Federal regulations in all areas of performance, including procedural and financial activities.
The Third-Party Liability Unit
The Third-Party Liability (TPL) Unit is responsible for identifying Medicaid beneficiaries who are dually-covered by Medicaid and any other medical insurance plans or other types of liability insurance, which are legally responsible for paying the beneficiaries' claims, and when
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necessary, ensuring that the Medicaid program is the payer of last resort by pursuing the liable third parties for reimbursement. The TPL Unit oversees the following programs: Casualty Recovery, Estate Recovery, Trust Recovery, Trust Approvals and Accountings Review, maintenance of health insurance policy updates that result in cost avoidance savings to the department, Credit Balance Audits, and reimbursement programs such as the Health Insurance Premium Program and the Children's Health Insurance Program Reauthorization Act for premium assistance.
The Background Investigations Unit
The Background Investigations Unit performs state and federal criminal history background investigations and financial background checks on behalf of the department, including the Office of Healthcare Facility Regulation, Medicaid and the Office of Human Resources. It is also responsible for the proper access, maintenance, storage and use of all criminal history record information obtained by the department.
The OIG Legal/State Health Benefit Plan (SHBP) Fraud Unit
The OIG Legal/State Health Benefit Plan Fraud Unit provides advice and representation for the division on all legal matters. It is also responsible for coordinating inquiries related to allegations of fraud, waste and abuse within the SHBP.
Georgia Caregiver Portal
OIG also oversees the Georgia Caregiver Portal which was signed into law in May 2018 by former Governor Nathan Deal. This portal allows families to determine the employment eligibility of a current employee or job applicant who is providing personal care services to that family's elderly family member. For more information please visit https://dch.georgia.gov/georgiacaregiver-portal.
Contact OIG
Office of Inspector General (OIG): 404-463-7481 Medicaid Fraud and Abuse Hotline (Toll-free): 1-800-533-0686 Special Investigations Unit: 404-232-1656 Third-Party Liability Unit: 404-657-9510 Medicaid Program Integrity Unit: 404-463-7437 Background Investigations Unit: 404 463-0110 Data Integrity and Analysis Unit: 404-463-7370 Office of Audits: 404-656-4905
Office of Inspector General 2 Peachtree Street, NW - 5th Floor Atlanta, GA 30303
To Report Fraud
E-mail: oiganonymous@dch.ga.gov
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Georgia Department of Community Health | 2 Peachtree Street NW, Atlanta, GA 30303 | www.dch.georgia.gov | 404-656-4507
January 2020