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Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral...
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Transcript of Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral...
![Page 1: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/1.jpg)
Program Integrity for Providersin Managed Care
Patrick Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review Section
![Page 2: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/2.jpg)
OBJECTIVES
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ObjectivesAt the completion of this presentation participants will be able to:
• Describe role DMA Program Integrity (PI)
• List one responsibility of the Behavioral Health Review Section (BHRS)
• Identify partnerships in combating fraud, waste, and abuse
![Page 4: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/4.jpg)
Medicaid Landscape
• Approximately 1.8 million Medicaid recipients
• Recipients in all 100 North Carolina counties
• 9 Behavioral Health Prepaid Inpatient Health Plans (PIHP) also known as Local Management Entities –Managed Care Organizations (LME-MCO)
• Under 3 year old population not covered by managed care
![Page 5: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/5.jpg)
Role of Program Integrity
![Page 6: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/6.jpg)
Role of Program Integrity
• Ensure compliance, efficiency, and accountability within the N.C. Medicaid
• Ensure that Medicaid dollars are paid appropriately
![Page 7: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/7.jpg)
Responsibilities of BHRS
• Perform post-payment reviews of MH/DD/SA providers.
• Conduct preliminary investigations on all complaints
![Page 8: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/8.jpg)
Responsibilities of BHRS
• Oversight and Monitoring of 9 PIHP program integrity activities
• Collaborate and/or coordinate with State agencies
![Page 9: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/9.jpg)
Responsibilities of BHRS All cases of credible allegations of fraud are referred to the Medicaid Investigation Division (MID).
PI-MID-PIHP meet quarterly to discuss program integrity-related activities in Managed Care.
![Page 10: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/10.jpg)
Partners
• Technology
• Prepayment Review
• Post-payment Review
• Investigations and Oversight
![Page 11: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/11.jpg)
Reporting and Analytics
![Page 12: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/12.jpg)
Reporting and Analytics
Audits and investigations are driven by data analytics and reporting systems associated with behavioral health providers.
![Page 13: Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section.](https://reader034.fdocuments.in/reader034/viewer/2022051114/56649e7f5503460f94b828fc/html5/thumbnails/13.jpg)
WHAT ARE YOUR QUESTIONS
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ContactPatrick Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review SectionNC Division of Medical AssistanceProgram Integrity Phone: 919-814-0143 Fax: 919-814-0035Email at [email protected] Website: http://www.ncdhhs.gov/dma