Communications
Bulletins 
Dec 7, 2018
Nov 9, 2018
Public Notices
SCDHHS Extends Public Comment Period for Community Engagement Section 1115 Demonstration Waiver Application
The South Carolina Department of Health and Human Services (SCDHHS) extends the public comment period for its Community Engagement Section 1115 Demonstration Waiver Application, which began Dec. 3, 2018, to a full 60 days. The public comment period will remain open until 5 p.m. Feb. 4, 2019.
Post date: 01/23/2019 - 8:45am
Public Notice of Final Action for the FFY 2019 DSH Payments and Swing Bed and Administrative Day Rate Changes
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following actions regarding its methods and standards for establishing Medicaid Disproportionate Share Hospital (DSH) payments to qualifying DSH hospitals, adjusting the SC Medicaid DSH Audit Redistribution Policy, and for updating the swing bed hospital and administrative d
Post date: 12/31/2018 - 4:05pm
Public Notice of Final Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
The South Carolina Department of Health and Human Services (Department), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 12/28/2018 - 4:10pm
Public Notice of Final Action for the Coverage of Opioid Treatment Program (OTP) Services
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding the coverage of opioid treatment program (OTP) services under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 12/28/2018 - 4:06pm
Community Engagement Section 1115 Demonstration Waiver Application
I. Overview
Post date: 12/03/2018 - 3:53pm
Public Notice of Proposed Action for the FFY 2019 DSH Payments and Swing Bed and Administrative Day Rate Changes
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed actions regarding its methods and standards for establishing Medicaid Disproportionate Share Hospital (DSH) payments to qualifying DSH hospitals, adjusting the SC Medicaid DSH Audit Redistribution Policy, and for updating the swing bed hospital and adminis
Post date: 11/28/2018 - 4:59pm
Public Notice of Proposed Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID
The South Carolina Department of Health and Human Services (Department), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed actions regarding its methods and standards for paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 11/28/2018 - 2:44pm
Public Notice of Proposed Action for the Coverage of Opioid Treatment Program (OTP) Services
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed action regarding the coverage of opioid treatment program (OTP) services under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 11/28/2018 - 1:51pm
Public Notice of Final Action for Non-Emergency Medical Transportation (NEMT) Nursing Facility Add-On
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payment rates for long term care facility services under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 09/28/2018 - 3:59pm
Public Notice of Final Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
The South Carolina Department of Health and Human Services (Department), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 09/28/2018 - 2:43pm
Public Notice of Final Action for Setting Payment Rates for Long Term Care Facility Services (Excluding State Owned Nursing Facilities)
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following actions regarding its methods and standards for setting payment rates for long term care facility services (excluding state owned nursing facilities) under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 09/20/2018 - 2:44pm
Public Notice of Proposed Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)
The South Carolina Department of Health and Human Services (Department), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed action regarding its methods and standards for paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 08/30/2018 - 2:32pm
Public Notice of Proposed Action for Non-Emergency Medical Transportation (NEMT) Nursing Facility Add-On
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed action regarding its methods and standards for setting payment rates for long term care facility services under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 08/29/2018 - 2:52pm
Proposed Action for Setting Payment Rates for Long Term Care Facility Services (Excluding State Owned Nursing Facilities)
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following proposed actions regarding its methods and standards for setting payment rates and Essential Public Safety Net payments for long term care facility services (excluding state owned nursing facilities) under the State Plan under Title XIX of the Social Security Act M
Post date: 08/08/2018 - 12:22pm
Comprehensive Preconception Care Model Waiver
PUBLIC Notice
SUBJECT: Comprehensive Preconception Care Model Waiver
Post date: 07/23/2018 - 1:57pm
Public Notice of Final Action for the Recovery Audit Contractor (RAC)
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following actions regarding an exception to 42 CFR § 455.502(b), which requires SCDHHS to contract with a Medicaid Recovery Audit Contractor (RAC) under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/29/2018 - 2:44pm
Public Notice of Final Action for Third Party Liability (TPL) Health Recovery CyclePublic Notice of Final Action for Third Party Liability (TPL) Health Recovery Cycle
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following actions regarding the TPL Health Recovery Cycle under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/29/2018 - 2:38pm
Public Notice of Final Action for the Psychiatric Residential Treatment Facility (PRTF) Rate Increase
The South Carolina Department of Health and Human Services (SCDHHS), pursuant to the requirements of Section 1902(a)(13)(A) of the Social Security Act, gives notice of the following action regarding its methods and standards for setting payments for the Psychiatric Residential Treatment Facilities (PRTFs) under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/25/2018 - 3:47pm
Public Notice of Proposed Action for Third Party Liability (TPL) Health Recovery Cycle
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed actions regarding the TPL Health Recovery Cycle under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/01/2018 - 3:26pm
Public Notice of Proposed Action for the Recovery Audit Contractor (RAC)
The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed actions regarding an exception to 42 CFR § 455.502(b), which requires SCDHHS to contract with a Medicaid Recovery Audit Contractor (RAC) under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/31/2018 - 4:50pm
Pages
Latest Press Releases
Mar 31, 2017
Governor Henry McMaster today announced Christian L. Soura’s resignation as Director of the South Carolina Department of Health and Human Services, effective April 7, 2017.
Jun 2, 2016
South Carolina Birth Outcomes Initiative Wins National Award for Innovative Strategies to Improve Health of Moms and Babies
Feb 23, 2016
Beginning April 1, the South Carolina Department of Health and Human Services (SCDHHS) will require that providers verify Medicaid members' controlled substance prescription history before issuing prescriptions for opioids
Feb 16, 2016
Project Aims To Reduce Preterm Births; Prevent Child Injury
Reports / Statistics
Posted: 12/13/2018 - 8:32am
The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse.
Posted: 04/01/2018 - 4:22pm
Posted: 02/02/2018 - 3:27pm
Posted: 12/05/2017 - 4:36pm
The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse.
Posted: 04/01/2017 - 2:44pm
Posted: 02/03/2017 - 10:50am
Posted: 01/19/2017 - 2:16pm
Submitted April 1, 2016
The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General’s Office for fraud and the recovery of funds lost due to fraud, waste and abuse.
The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars each year. Other estimates by government and law enforcement agencies such as the FBI place the loss due to health care fraud as high as 10 percent of annual health care expenditures. Federal regulations define fraud as “intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.” (42CFR 455.2) Medicaid fraud is a criminal matter. Waste, improper claims, billing errors, and abuse also cause losses of Medicaid funds but are not criminal actions.
SCDHHS receives fraud “tips” from its fraud hotline and also conducts extensive data mining to identify potential fraud cases. Federal regulations require SCDHHS to conduct a preliminary investigation upon suspicion of fraud and then refer the cases to the Medicaid Fraud Control Unit (MFCU) in the SC Attorney General’s Office. Cases are also referred to the MFCU from other sources, such as the FBI, the federal Office of Inspector General, other state agencies, and the MFCU’s own fraud hotline. SCDHHS’ Division of Program Integrity conducts these preliminary investigations and collaborates with the MFCU on all fraud cases. Fraud cases can take several years before final adjudication and the collection of any penalties or claim refunds by SCDHHS.
The MFCU also participates in national global cases that arise in connection with a U.S. Department of Justice investigation. Those cases oftentimes involve manipulation of wholesale drug prices by pharmaceutical companies to increase Medicaid payments. While considered fraud cases, they are prosecuted as civil cases as opposed to criminal cases. In calendar year 2015 thirteen (13) settlements resulted from cases originating out of the National Association of Medicaid Fraud Control Unit (NAMFCU) actions resulting in recoveries of $6,606,395.75.
The following table illustrates Medicaid provider fraud cases that were opened during calendar year 2015 and reflects the number of settlements and convictions that occurred during calendar year 2015. The percent of fraud cases referred by SCDHHS was 27%. Total 2015 calendar year recoveries were $11,866,071.32. Federal laws and regulations require the return of the federal share of Medicaid funds recovered. Approximately 68% of the recovered amount must be returned to the federal government. SCDHHS can retain the state share (approximately 32%) of the recoveries and re-use the funds to again match federal monies for the on-going operation of the Medicaid program.
| Provider Fraud Cases | |
| New Provider Fraud Cases Opened * | 94 |
| Active * | 54 |
| Closed * | 40 |
| Number / % Referred by SCDHHS # | 21 / 27% |
| Results | |
| Recovered as a result of Provider Fraud Convictions/Referrals1 | $467,695.24 |
| Recoveries from all other PI cases1,2 | $4,791,980.33 |
| Convictions | 12 |
| National Association of Medicaid Fraud Control Units (NAMFCU) | |
| # Of Cases Settled | 13 |
| Amounts Recovered1 | $6,606,395.75 |
1. All dollars shown are combined federal and state. Some of the recoveries in 2015 are from cases opened in prior year(s).
2. Program Integrity recoveries due to cases for waste, overpayments, improper payments, and abuse that were not referred for potential fraud.
* Includes Globals
# Does Not Include Globals
Posted: 04/01/2016 - 12:02pm
Posted: 03/16/2016 - 2:36pm
Posted: 02/03/2016 - 9:57am
Posted: 12/08/2015 - 3:46pm
Posted: 10/21/2015 - 5:01pm
Submitted April 1, 2015
The South Carolina Department of Health and Human Services (SCDHHS) engages in an on-going effort to prevent and identify fraud in the Medicaid program, and to recover the funds lost because of fraudulent and excessive practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is even more critical because of the need to better manage scarce public resources in a time of rising demand and decreasing tax dollars. The department is committed to increasing the quality and number of cases referred to the SC Attorney General's Office for fraud and the recovery of funds lost due to fraud, waste and abuse.
The National Health Care Anti-Fraud Association estimates that financial losses due to health care fraud are in the tens of billions of dollars each year. Other estimates by government and law enforcement agencies such as the FBI place the loss due to health care fraud as high as 10 percent of annual health care expenditures. Federal regulations define fraud as ¡§intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.¡¨ (42CFR 455.2) Medicaid fraud is a criminal matter. Waste, improper claims, billing errors, and abuse also cause losses of Medicaid funds but are not criminal actions.
SCDHHS receives fraud ¡§tips¡¨ from its fraud hotline and also conducts extensive data mining to identify potential fraud cases. Federal regulations require SCDHHS to conduct a preliminary investigation upon suspicion of fraud and then refer the cases to the Medicaid Fraud Control Unit (MFCU) in the SC Attorney General¡¦s Office. Cases are also referred to the MFCU from other sources, such as the FBI, the federal Office of Inspector General, other state agencies, and the MFCU¡¦s own fraud hotline. SCDHHS¡¦ Division of Program Integrity conducts these preliminary investigations and collaborates with the MFCU on all fraud cases. Fraud cases can take several years before final adjudication and the collection of any penalties or claim refunds by SCDHHS. In general, healthcare fraud involves filing a false claim for Medicaid payments, which can include services that were never provided, or were provided but were not medically necessary. The MFCU also participates in national cases against pharmaceutical companies that manipulate wholesale prices on drugs to get more money from Medicaid. While these are also considered fraud cases, they are prosecuted as civil cases as opposed to criminal cases.
The following table reports Medicaid provider fraud cases that were opened during calendar year 2014 updated for the most current data available through December 31, 2014; the amounts recovered by the Attorney General¡¦s Office and Program Integrity and the number of convictions for the same time frame; and the number of recoveries from civil settlements in the national pharmaceutical cases. The federal share of the Medicaid funds recovered (approximately 68%) must be returned; SCDHHS can retain the state share of these recoveries and use it to again match federal monies for the on-going operation of the Medicaid program.
The total number of on-going cases for Medicaid provider fraud at the Attorney General¡¦s totaled 136, to include pharmaceutical cases, as of December 31, 2014; 79 of these cases were referred by SCDHHS. This includes cases that were opened in previous years (and therefore not counted in the table below) but are still on-going as of the January 16, 2015, based on the Provider Case List provided by the Attorney General¡¦s Office.
| Provider Fraud Cases | |
| New Provider Fraud Cases Opened * | 78 |
| Active * | 38 |
| Closed * | 40 |
| Number / % Referred by SCDHHS # | 24 / 30.77 % |
| Results | |
| Recovered as a result of Provider Fraud Convictions/Referrals (1) | $246,512.64 |
| Recoveries from all other PI cases (2) | $4,382,490.82 |
| Convictions | 11 |
| Pharmaceutical Manufacturer Cases | |
| # Of Cases Settled | 18 |
| Amounts Recovered (3) | $21,524,869.91 |
- All dollars shown are federal and state; the state share is approximately 32%. Some of the recoveries in 2014 are from cases opened in prior year(s).
- Program Integrity recoveries due to cases for waste, overpayments, improper payments, and abuse that were not referred for potential fraud.
- 58% of the recoveries from global pharmaceutical manufacturer cases are state funds.
* Includes Pharmaceuticals # Does Not Include Pharmaceuticals
Posted: 04/01/2015 - 10:56am
Posted: 03/19/2015 - 1:54pm
Posted: 02/04/2015 - 9:30am
The Department of Health and Human Services shall establish a procedure to assess the various forms of health care delivery systems to measure cost effectiveness and quality. These measures must be compiled on an annual basis on identifiable benchmarks. These measures must broadly address agency program areas and initiatives using national and state measures. Cost effectiveness shall be determined in an actuarially sound manner and data must be aggregated in a manner to be determined by a third party. The methodology must use appropriate case-mix and actuarial adjustments. The department shall issue an annual healthcare report of statewide measures deemed appropriate by the department required under state and federal guidelines. The report shall be formatted in a clear, concise manner in order to be easily understood by Medicaid beneficiaries and other stakeholders. The annual results of the cost effectiveness calculations, quality measures and the report cards shall be made public on the department's website by December thirty-first for the prior state fiscal year.
Posted: 01/22/2015 - 3:38pm
Posted: 11/20/2014 - 4:33pm
Posted: 11/20/2014 - 4:31pm
Modular is Hard but Possible
John Supra
Deputy Director & CIO
MESC 2014 – Denver, Colorado
Posted: 08/21/2014 - 8:14pm