Bureau of Compliance and Performance Review

The chief goal of the Bureau of Compliance and Performance Review is to ensure that Medicaid and other funds are used effectively, efficiently, and in compliance with applicable state and federal laws and policies. This bureau comprises three divisions: Program Integrity, Internal Audit, and Surveillance and Utilization Review.

Division of Program Integrity

The Division of Program Integrity is part of a statewide surveillance and utilization control system that safeguards against fraudulent, abusive, inappropriate, and excessive use of Medicaid. This division manages the fraud and abuse hotline, receives tips about suspected Medicaid fraud and abuse, and conducts investigations of individual health care providers and Medicaid beneficiaries. If Medicaid provider fraud is suspected, Program Integrity turns the case over to the Medicaid Fraud Control Unit in the State Attorney General's office. Beneficiary fraud cases are referred to the Medicaid Recipient Fraud Unit at the State Attorney General's offices.

If you suspect a health care provider or a beneficiary is using the Medicaid program in an abusive or fraudulent manner, please call the Program Integrity Medicaid Fraud and Abuse Hotline at
1-888-364-3224.

Program Integrity also conducts post-payment reviews directed towards reclaiming Medicaid funds that have been wasted through inaccurate, excessive, or duplicate payments. The division uses various means to identify overpayments to health care providers, including medical utilization reviews, on-site audits of clinical and financial records, provider "self-audits," claims data analysis, and payment accuracy studies. When an overpayment is identified, the provider is required to repay the Medicaid funds or to have the amount deducted from the next reimbursement.

In addition, Program Integrity uses claims information to identify those Medicaid beneficiaries who show a pattern of excessive and uncoordinated use of prescription drugs and other Medicaid benefits. Beneficiaries who meet certain criteria, such as using multiple pharmacies within a short period of time, can be placed in a Pharmacy Lock-In Program. Th Pharmacy Lock-In program allows beneficiaries to choose only one pharmacy to fill their Medicaid prescriptions, which helps reduce improper or harmful use of prescription medicines.

The Division of Program Integrity also is responsbile for excluding Medicaid providers in accordance with federal reguations and for managing information about excluded providers.

Excluded Provider List

What is an excluded provider? An excluded provider is an individual or entity that cannot bill or cause services to be billed to Medicaid, Medicare, The State Childrens' Health Insurance Program (SCHIP), the Block Grant for Social Services and other federally-funded health care programs. Most exclusions are for a period of three to five years, although exclusion from Medicaid or other federally-funded health care programs can be permanent. The following website gives additional information on the effect of exclusions on participation in federal programs:

The Effect of Exclusion From Participation in Federal Health Care Programs

The State of South Carolina works diligently to prevent excluded providers from participating in the SC Medicaid program in order to comply with the federal regualtions.

Below is a list of individuals and entities that have been excluded by the federal government and/or the State of South Carolina. Anyone appearing on this list should not submit claims for Medicaid reimbursement and should not be affiliated with any organization or facility that participates in the Medicaid program. In addition, providers cannot bill for any medicines, medical supplies or medical equipment that is prescribed or authorized by an excluded provider on behalf of a Medicaid beneficiary. If an organization or facility employs an excluded individual, this can result in the entire organization being excluded from the SC Medicaid program. Any questions can be directed to Patricia Godley at 803-898-3003.

Newly added excluded providers will be highlighted in yellow for their first 60 days on the South Carolina Excluded Providers list.

The Division of Audits

The South Carolina Department of Health and Human Services (SCDHHS) was created in 1984 pursuant to \A71-30-10 et. seq. of the SC Code of Laws. The SC Code of Laws, \A744-6-30, mandates that SCDHHS administer the Medicaid program (Title XIX of the Social Security Act). The DHHS Division of Audits was formed to assist the agency in the management, assessment, and improvement of agency programs, services, and operations. The Division of Audits accomplishes these goals by reviewing and evaluating programs and contracts administered by DHHS to determine the extent to which fiscal, administrative, and programmatic objectives are met in a cost effective manner. Another goal of the division is to bring a systematic, disciplined approach to evaluate and improve the effectiveness of risk management, control and governance processes.

The Division of Audits conducts several kinds of audits and reviews, including

  • Audits of contracts for services funded by Medicaid,
  • Audits of agency internal functions and management controls,
  • Audits of cost reports submitted by other state agencies and Medicaid providers, and
  • Evaluations of Medicaid-funded programs to ensure that funds are spent appropriately and efficiently.

Audit reports are based on verifiable, reliable, and documented evidence relevant to the specific audit objectives. The end result of every report is to produce recommendations to help agency management make decisions about contracts, policies, and spending priorities. The audit division also identifies overpayments.

In performing its audits, the Division of Audits follows the Governmental Auditing Standards (revised July 2007) issued by the United States Governmental Accountability Office (GAO). Where applicable, the Division of Audits may follow professional standards issued by other bodies such as the Institute of Internal Auditors' Codification of Standards for the Professional Practice of Internal Auditing, as well as the Generally Accepted Auditing Standards issued by the American Institute of Certified Public Accountants.

Government Auditing Standard requires that audit organizations have an independent peer review is performed periodically, resulting in an opinion issued as to whether an audit organization's system of quality control is designed and followed in order to provide reasonable assurance of conforming with professional standards. The Division of Audits met this requirement and received a commendable rating.

The Division of Surveillance and Utilization Review

The Division of Surveillance and Utilization Review manages and operates the federally-required Surveillance Utilization Review System (SURS), a database management and analysis system. The SURS is a powerful, data analysis tool that searches through millions of Medicaid claims to detect aberrant trends, outliers, and unusual billing patterns that can indicate waste, fraud, and abuse. Program Integrity and Audit staff, as well as other divisions throughout the agency, use SURS reports continuously in their work. In federal fiscal year 2007, about 64% of Program Integrity reviews were initiated through data mining and analysis as opposed to complaints.

 

 

 

ADDITIONAL LINKS: 

http://www.scattorneygeneral.org/public/medicaid.html

http://cms.hhs.gov

 

 




Contact Info


P.O.Box 8206
Columbia, SC 29202-8206
Division of Audits 803-898-8881
Fraud Hotline 1-888-364-3224