Communications
Public Notices
Waiver Renewal for the Community Choices (CC) and HIV/AIDS Waivers
Public Notice of Final Action for Medication-Assisted Treatment
Heightened Scrutiny Category 2 Settings: Submission to CMS; South Carolina Home and Community-Based Services Statewide Transition Plan updates
Palmetto Coordinated System of Care 1915(c) Waiver Amendment
Final Action for Setting Payment Rates for Long Term Care Facility Services (Excluding State-Owned Nursing Facilities)
Final Action for FFY 2021 DSH Payments and Swing Bed Hospital and Administrative Day Rates
State Community Engagement Implementation Task Force
Amendment for the Medically Complex Children (MCC) Waiver
Proposed Action for Setting Payment Rates for Long Term Care Facility Services (Excluding State-Owned Nursing Facilities)
Proposed Action for FFY 2021 DSH Payments and Swing Bed Hospital and Administrative Day Rates
Amendment for the Medically Complex Children (MCC) Waiver
Public Notice of Final Action for Professional Service Fee Schedules
Public Notice of Final Action for Medicaid Coverage of Contraceptives
Public Notice of Final Action for Early Intervention/Family Training Services Program Rate Increase
Public Notice of Proposed Action for Medicaid Coverage of Contraceptives
Final Action for the Introduction of Therapeutic Foster Care for Child Medicaid Beneficiaries
Public Notice of Final Action for Covered Outpatient Drug Reimbursement Methodology Update
Public Notice of Final Action for the Supplemental Teaching Physician (STP) Payment Program
Public Notice of Proposed Action for the Supplemental Teaching Physician (STP) Payment Program
Amendment for the Community Choices Waiver and Waiver Specific Transition Plan
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Latest Press Releases
The South Carolina Department of Health and Human Services (SCDHHS) announced it will immediately begin accepting applications for a new limited-benefit Medicaid coverage group to provide reimbursement for coronavirus disease 2019 (COVID-19) testing for those without healthcare coverage. SCDHHS’ COVID-19 Limited Benefit Program was authorized by the Families First Coronavirus Response Act (FFCRA) and will provide additional financial support to increase access to testing, a critical component of the state’s response to addressing the pandemic, for South Carolinians without other sources of healthcare coverage.
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.
South Carolina Birth Outcomes Initiative Wins National Award for Innovative Strategies to Improve Health of Moms and Babies
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
Reports / Statistics
Posted: 02/03/2021 - 11:39am
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 wasteful practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is critical because of the need to assure that public resources are properly managed.
Posted: 04/09/2020 - 3:03pm
Posted: 01/29/2020 - 2:38pm
Posted: 12/12/2019 - 10:04am
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 wasteful practices on the part of healthcare providers. Not only is this mandated by federal regulations found in 42 CFR 455, it is critical because of the need to assure that public resources are properly managed.
Posted: 03/21/2019 - 4:12pm
Posted: 12/13/2018 - 8:27am
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