Communications

 

Public Notices

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 for long-term care facility services (excluding state-owned nursing facilities) under the South Carolina Medicaid State Plan (State Plan) under Title XIX of the Social Security Act Medic
Post date: 08/16/2019 - 5:23pm

Final Action for Reimbursement Changes for Medications Purchased through the 340B Program

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding reimbursement for medications purchased through the 340B program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).  
Post date: 06/28/2019 - 5:18pm

Final Action for Autism Spectrum Disorder (ASD) Rate Setting Methodology

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding autism spectrum disorder (ASD) services under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/28/2019 - 2:02pm

Final Action for the Incorporation of Institutions for Mental Diseases and Opioid Treatment Program Clinics in the Coordinated Care Benefit

The South Carolina Department of Health and Human Services (SCDHHS) gives notice regarding the inclusion of benefits for inpatient psychiatric care for children delivered in institutions for mental diseases (IMDs) and for services provided in opioid treatment program (OTP) clinics to capitated managed care, pursuant to the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/28/2019 - 12:46pm

Final Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

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 paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 06/28/2019 - 11:16am

Final Action for Professional Service Fee Schedules

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following action regarding professional service fee schedules under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid). Effective for dates of service on and after July 1, 2019, SCDHHS will amend the South Carolina Title XIX State Plan to update the fee schedule for providers indicated below. 
Post date: 06/28/2019 - 11:26am

Proposed Action for the Incorporation of Institutions for Mental Diseases and Opioid Treatment Program Clinics in the Coordinated Care Benefit

The South Carolina Department of Health and Human Services (SCDHHS) gives notice regarding the inclusion of benefits for inpatient psychiatric care for children delivered in institutions for mental diseases (IMDs) and for services provided in opioid treatment program (OTP) clinics to capitated managed care, pursuant to the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/30/2019 - 3:43pm

Proposed Action for Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

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 paying providers under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/30/2019 - 2:43pm

Proposed Action for Autism Spectrum Disorder (ASD) Rate Setting Methodology

The South Carolina Department of Health and Human Services (SCDHHS) gives notice of the following proposed action regarding autism spectrum disorder (ASD) services under the state plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 05/30/2019 - 2:23pm

Final Action for the Supplemental Teaching Physician (STP) Payment Program

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 Supplemental Teaching Physician (STP) Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 03/29/2019 - 2:09pm

Community Engagement Section 1115 Demonstration Waiver Application

Public notice is hereby given that South Carolina Department of Health and Human Services (SCDHHS) intends to apply for a new section 1115 demonstration waiver to the Centers for Medicare & Medicaid Services (CMS) to promote South Carolina Healthy Connections Medicaid beneficiaries’ health and well-being through incentivizing community engagement.
Post date: 03/04/2019 - 7:28pm

Public Notice of Proposed Action for the Supplemental Teaching Physician (STP) Payment Program

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 payments for the Supplemental Teaching Physician (STP) Payment Program under the State Plan under Title XIX of the Social Security Act Medical Assistance Program (Medicaid).
Post date: 03/01/2019 - 2:41pm

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 - 8:43am

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 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

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

Community Engagement Section 1115 Demonstration Waiver Application

I. Overview 
Post date: 12/03/2018 - 12:31pm

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 - 4:57pm

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 - 2:43pm

Pages

Latest Press Releases RSS icon

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

Reports / Statistics

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.

Download Full Presentation

Posted: 03/21/2019 - 4:12pm

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.

 

Download Full Presentation

Posted: 04/01/2018 - 4:22pm

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. 

Download Full Report

Posted: 04/01/2017 - 2:44pm

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.

FRAUD CASES 2015
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

 

Print Version

Posted: 04/01/2016 - 12:02pm

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.

FRAUD CASES 2014
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

 

  1. 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).
  2. Program Integrity recoveries due to cases for waste, overpayments, improper payments, and abuse that were not referred for potential fraud.
  3. 58% of the recoveries from global pharmaceutical manufacturer cases are state funds.

 

* Includes Pharmaceuticals # Does Not Include Pharmaceuticals

 

Print Version

Posted: 04/01/2015 - 10:56am

SCDHHS Budget Presentation
February 3, 2015

Download Full Presentation

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

SCDHHS Budget Presentation
November 20, 2014
 

Posted: 11/20/2014 - 4:33pm

SCDHHS Budget Presentation
November 20, 2014
 

Posted: 11/20/2014 - 4:31pm

Pages

Report Fraud