An overview of the Office of Inspector General [Jan. 2012]

An Overview of the Office of Inspector General
Overview
The purpose of the Office of the Inspector General (OIG) is to provide department oversight, audit, and provider enrollment certification services for the Department of Community Health (DCH) OIG's mission is to reduce fraud, waste, and abuse; increase assurances concerning the safety and security of the program members; and have confidence in the value delivered to the taxpayer.
Programs
Program Integrity Internal Investigations Provider Enrollment Office of Audits
Program Integrity
The Program Integrity Unit (PI) is charged with the responsibility of monitoring the utilization habits and patterns of both members and providers of the Medicaid community. PI consists of six teams including: Facility, Data Integrity and Analysis, Professional Services, Pharmacy, Waivers and Investigations.
The PI Section covers the entire state of Georgia.
Patterns of fraud and abuse by Providers can include, but are not limited to: Filing claims for a higher level service than was actually performed, also referred to as "up-coding" Billing for services before service is actually rendered Altering claim forms and patient records Billing for non-covered services Performing services that are not medically necessary
Patterns of fraud and abuse by Members can include, but are not limited to: Drug over-utilization or over-utilization of services Criminal activity involved in securing medical services (such as forged prescriptions) Repeated failure to safeguard the Medicaid card Providing incorrect information or allowing others to do so in order to obtain Medicaid eligibility Failure to report changes which occur in income, living arrangements, or resources
continued Georgia Department of Community Health | 2 Peachtree Street NW, Atlanta, GA 30303 | www.dch.georgia.gov | 404-656-4507
January 2012

An Overview of OIG
Internal Investigations
The Internal Investigations Unit is charged with the responsibility of: Employee misconduct involving allegations of legal violations against DCH Employee misconduct involving Standards of Conduct, Ethics and Conflict of Interest policy violations Fraud, waste and abuse involving DCH employees, contractors, sub-contractors and vendors Other activities that could potentially have a negative impact on the integrity of DCH, its reputation, and its employees
Provider Enrollment
OIG's Provider Enrollment is responsible for reviewing, evaluating and processing all applications for supplier and facility enrollment in the Georgia Medicaid and PeachCare for Kids programs.
The section also oversees and monitors the review and processing of practitioner applications which is conducted by its fiscal agent, Hewlett-Packard Enterprise Services (HPES).
Office of Audits
The DCH Office of Audits is responsible for both internal and external audits and reviews. In the near future, the office will do programmatic reviews/audits of programs within DCH as well.
The main function of the DCH Office of Audits is to perform, coordinate, monitor and assist in all internal and external audits occurring at DCH. The office works with the Georgia Department of Audits and Accounts, all other auditors and DCH staff before, during and after an audit to ensure that they receive what they need to complete their work.
In addition, the office receives and reviews disposition audits/audit reports. Staff attends all entrance and exit conferences that pertain to an audit. They also help write, implement and follow-up on corrective actions as the result of an audit. Staff then writes letters of agreement or disagreement related to audits or findings to be referred back to the initiating entity.