1. Program Integrity for Providers in Managed Care Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section

2. OBJECTIVES

3. Objectives At 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

4. 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

5. Role of Program Integrity

6. Ensure compliance, efficiency, and accountability within the N.C. Medicaid Ensure that Medicaid dollars are paid appropriately

7. Responsibilities of BHRS Perform post-payment reviews of MH/DD/SA providers. Conduct preliminary investigations on all complaints

8. Responsibilities of BHRS Oversight and Monitoring of 9 PIHP program integrity activities Collaborate and/or coordinate with State agencies

9. 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.

10. Partners Technology Prepayment Review Post-payment Review Investigations and Oversight

11. Reporting and Analytics

12. Audits and investigations are driven by data analytics and reporting systems associated with behavioral health providers.

13. WHAT ARE YOUR QUESTIONS

14. Contact Patrick Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section NC Division of Medical Assistance Program Integrity Phone: 919-814-0143 Fax: 919-814-0035 Email at Patrick.Piggott@dhhs.nc.govPatrick.Piggott@dhhs.nc.gov Website: http://www.ncdhhs.gov/dmahttp://www.ncdhhs.gov/dma