A snapshot of Office of Inspector General

A Program Of The Georgia Department Of Community Health
A SNAPSHOT OF
Office of Inspector General
Overview The Office of Inspector General's (OIG) mission is to help safeguard the Georgia Department of Community Health from risk, both internally and externally. This is accomplished by
Ensuring the safety and security of the Medicaid member; and Leveraging the available resources to achieve the best value for the taxpayer.
OIG carries out its mission by rigorously investigating and auditing Georgia Medicaid providers and members to uncover criminal conduct, administrative wrongdoing, poor management practices, waste, fraud and other abuses by participating organizations.
Four units conduct this mission: Program Integrity Medicaid & WIC Investigations Audits Internal Investigations
Each unit ensures the fiscal responsibility and ethical conduct of employees and vendors.
Units and Duties The Program Integrity (PI) unit seeks to ensure that Georgia tax payer funds are utilized in a responsible manner and to exercise fiscal oversight over both state and federal funds. PI also seeks to ensure that eligible members have access to health care facilities and health care professionals to receive quality care throughout Georgia, and educate providers about compliance regulations in accordance with the policies and procedures established by state and federal guidelines. It is also the responsibility of PI to ensure that all personal health information (PHI) is handled in a safe and secure manner during the collection and review processes.
The PI teams generate profiles based on billed claims, and utilization patterns of Medicaid providers and members that are based on user defined parameters and other criteria. By analyzing and comparing providers to their respective peer groups, abnormal patterns of practice can be identified during the PI review.
PI staff members identify aberrant behaviors and conduct hospital, physician and other provider type audits to educate providers on program guidelines, and recover inappropriately reimbursed funds.
When potential patterns of over utilization, fraud or abuse are received or identified, PI uses several methods to substantiate this information, including but not limited to:
Onsite visits to provider locations Member surveys to verify services were rendered Claims analysis for members and providers Peer comparisons Medical records reviews
2 Peachtree Street, Atlanta, Ga 30303 w www.dch.georgia.gov January 2011

A Snapshot of
Office of Inspector General
The Medicaid Investigations unit is charged with the primary responsibility to identify and investigate fraud and abuse within the Medicaid and PeachCare for KidsTM programs (both provider and member).
When investigations are complete and a complaint has been corroborated, provider cases are referred to the State Health Care Fraud Control Unit and member cases are referred to local law enforcement or the district attorney's office located within the jurisdiction of where the crime occurred.
OIG also works with Health and Human Services-OIG and the FBI on cases that cross between Medicaid, Medicare and private insurance. These cases are usually prosecuted by the US Attorney's Office.
The WIC Investigations unit conducts covert investigations of WIC vendors that are identified as being high risk or have had complaints filed against them with DCH-OIG. When investigations and cases are completed and there is evidence to show that policy violations have been committed, the vendors are submitted for disqualification from the program. If the investigations reveal criminal violations, the cases are submitted to United States Department of Agriculture-OIG for criminal prosecution.
The Audits unit oversees external audits performed within the Department and performance reviews of internal functions. The unit also monitors and tracks all federal and state audits of the Department on a regular or ad hoc basis, depending on what is necessary. The unit then examines internal processes and makes recommendations for improvement.
The Internal Investigations unit examines employee and vendor misconduct. This unit investigates allegations of misconduct and makes recommendations to the Commissioner for steps of action. It also performs background checks on all job applicants prior to making formal offers of employment.
As stewards of tax payer money, the Department holds its employees and vendors to the highest moral and ethical standards.