NC State Auditor Says: NC DMA Program Integrity Poorly Run!!
We all knew this already, right? The Program Integrity Section (PI) of the Division of Medical Assistance (DMA) is poorly run…that’s not new news, right? Shoot, I could have told you PI was poorly run for free, instead of wasting 16,411 audit hours at an approximate cost of $1,181,592.
“10. DEFICIENCIES WITH PROGRAM INTEGRITY FUNCTIONS
The Department did not adequately track case investigations, consistently maintain case file documentation, and establish an effective quality assurance process over the Public Consulting Group, a post-payment review contractor. These deficiencies could result in failures in completing case investigations, identifying provider overpayments, and referring potentially fraudulent cases to the Attorney General’s Medicaid Investigations Unit. Federal regulations require the establishment of procedures to identify suspected fraud cases, investigate these cases, and refer cases with sufficient evidence of suspected fraud to law enforcement officials.”
(I added the red ink for emphasis).
STOP THE PRESSES!!! Is this audit stating on public record that PI has NOT established effective quality assurance process over PCG????
I am quite certain that many of my clients would have rather learned this little “tid bit” of knowledge BEFORE PCG told my clients that they owed the State hundreds of thousands of dollars. BEFORE my clients had to hire me. BEFORE some providers (not my clients) have declared bankruptcy from PCG’s allegations that the provider owed hundreds of thousands of dollars.
Maybe PI’s deficiencies contribute to the reason that health care providers that try to contact PI with questions about their own cases are unable to find someone knowledgable and willing to speak with them and provide detailed reasons for PI’s or PCG’s findings. (Just a guess).
“The Department agrees with the finding and recommendations. The Program Integrity (PI) case tracking database is an Access database created six years ago that now contains 50,000 records. Due to the volume of records contained in the PI case tracking system, it is extremely unstable and has weekly issues. In addition, the 2008 Centers for Medicare and Medicaid Services (CMS) audit cited the Division of Medical Assistance for not maintaining an effective fraud and abuse case tracking system. PI continues in its effort to procure an effective PI case tracking system to ensure case file documentation is maintained. In the interim, PI conducts monthly quality assurance reviews for all contractors performing case investigations to ensure the quality assurance review process is strengthened.”
Hmmmmm…Seems that PI needs some quick and drastic reform. But not only PI….but also PCG, which apparently is running rampant and with little to no supervision.
I literally cannot wait until the State Auditor audits DMA and the conduct of Managed Care Organizations (MCOs).
Posted on April 9, 2013, in Beth Wood, Division of Medical Assistance, Health Care Providers and Services, Medicaid, Medicaid Audits, NC DHHS, North Carolina, Office of State Auditor, Tentative Notices of Overpayment and tagged Audit, Beth Wood, Division of Medical Assistance, Health care provider, Medicaid, Public Consulting Group. Bookmark the permalink. 4 Comments.