A snapshot of Program Integrity

A Program Of The Georgia Department Of Community Health
A SNAPSHOT OF
Program Integrity

Overview

The Office of Inspector General was created in 2006 to safeguard the department from internal and

external risk. Three units conduct this mission:



Program Integrity



Audits



Internal Investigations

Each unit ensures the fiscal responsibility and ethical conduct of employees and vendors.

Units and Duties

The Program Integrity (PI) unit is responsible for detecting fraud, waste and abuse in the Medicaid and PeachCare for KidsTM programs. The unit identifies, investigates and recovers funds spent inappropriately. When fraud is discovered, cases are transferred to the State HealthCare Fraud Control unit for investigation and prosecution. All other cases are thoroughly reviewed and pursued when the unit receives complaints, data research points to abuse or providers selfdisclose.

Complaints are received through a telephone hotline, the internet, and internal referrals, and then they are triaged and assigned to an investigator for review. The investigator then corroborates the complaint with additional information. After the complaint is validated, the case is routed to a clinical team for full review.

Data research identifies abuse within a category of service which may be occurring with several providers. Statistics analysts use the latest technology to detect suspicious billing patterns and identify providers. Reports are then produced that assist clinicians in identifying providers they will then review.

When providers identify potential overpayments, they can look at specific departmental policies about how to report their findings. The PI unit will identify areas of potential abuse and notify all of the providers within that category of service of the issue. Providers are then encouraged to selfexamine and self-disclose.

PI investigates services ranging from primary care physicians' practices to institutional health care. The unit is also responsible for the oversight of health care related activities such as mental health, therapy and pharmaceuticals. In addition to provider reviews, the PI unit investigates recipients alleged to be abusing or defrauding the Medicaid and PeachCare for KidsTM programs.

The PI unit works with the State HealthCare Fraud Control unit, local prosecutors and federal agencies to identify and adjudicate Medicaid fraud and abuse. PI also assists the State HealthCare Fraud Control unit in recovering funds through global pharmaceutical settlements with the National Association of Medicaid Fraud Control units and the United States Department of Justice.

2 Peachtree Street, Atlanta, Ga 30303 www.dch.georgia.gov

February 2009

A Snapshot of
Program Integrity
The Audits unit oversees external audits performed in 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, and 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 about action steps. 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.