OA-Bureau of Program Integrity | Department of Human Services | Commonwealth of Pennsylvania

OA-Bureau of Program Integrity | Department of Human Services | Commonwealth of Pennsylvania
OFFICE OF ADMINISTRATION
Bureau of Program Integrity
The Bureau of Program Integrity (BPI) ensures Medicaid recipients receive quality medical services and that these recipients do not abuse their use of medical services; applies administrative sanctions; refers cases of potential fraud to the appropriate enforcement agency; and evaluates medical services rendered by medical providers and managed care organization (MCO) provider networks.
​Overview
The Bureau of Program Integrity (BPI) ensures Medical Assistance (MA) recipients receive quality medical services and that MA recipients do not abuse their use of medical services; applies administrative sanctions; refers cases of potential fraud to the appropriate enforcement agency; and evaluates medical services rendered by medical providers and managed care organization (MCO) provider networks. The bureau monitors MA recipient overuse and abuse of medical services; maintains ongoing working relationships with federal and state enforcement agencies involved in monitoring potential health care fraud and abuse and ensures feedback is provided to the Department of Human Services (DHS) to enhance program performance. The bureau manages the federally mandated cost containment program designed to identify the use of, and recovery from, third party benefits available to MA recipients, and administers the Estate Recovery Program and the Health Insurance Premium Payment (HIPP) Program.
Bureau staff include medical professionals responsible for preventing, detecting, deterring, and correcting fraud, abuse and wasteful practices by providers of MA services, including MCOs; applying administrative sanctions; and referring cases of potential fraud to the appropriate enforcement agency. This responsibility includes evaluating services rendered by medical providers and MCO provider networks, monitoring recipient overuse and abuse, and maintaining ongoing working relationships with federal and state enforcement agencies involved in monitoring potential health care fraud and abuse.
Report Suspected Fraud or Abuse
To report suspected fraud or abuse of services provided under the MA program please:
Call
the Bureau of Program Integrity at
1-844-DHS-TIPS (1-844-347-8477)
Submit
a completed form:
MA Provider Compliance Hotline Response Form
, or
Write
to us at:
Department of Human Services
Bureau of Program Integrity
Commonwealth Tower, Floor 4
P.O. Box 2675
Harrisburg, PA 17105-2675
Additional information about MA Fraud and Abuse can be found in the
Fraud and Abuse
section of this web site.
In addition, the federal government has developed a set of frequently asked questions to assist providers who receive audit requests:
Medicaid Integrity Program (MIP), Provider Audits - Frequently Asked Questions
Program Integrity Organization:
Administrative Unit
Division of Provider Review
Behavioral Health Review Section
Home and Community Based Services Section
Medical Services Support Section
Division of Program and Provider Compliance
Hospital-Based Services Section
Practitioner/Recipient Restriction Section
School-Based Access, Ambulance, and Pharmacy Review Section
Program Support and Analysis Unit
Integrity Management Section
Managed Care Organization Section
Referral and Program Support Section
Administrative/Program Support Unit
The Administrative/Program Support Unit oversees all activities relating to human resources, budgeting, travel, and procurement, including contracting. This unit also provides program support functions to assist in carrying out the mission and goals of the bureau, and to assist in the development and implementation of any new initiatives that are undertaken.
Division of Provider Review
The Division of Provider Review (DPR) identifies, reviews, and investigates cases of fiscal and programmatic abuse of the MA program. The division also handles self-audits submitted by specific provider types reviewed within the division's sections. DPR is responsible for reviewing providers and services whether administered by fee-for-service providers or MCOs under contract to DHS.
The sections within this division are:
Behavioral Health Review Section
Home and Community Based Services Section
Medical Services Support Section
The Behavioral Health Review Section is responsible for the review and oversight of all mental health, developmental disabilities, and drug and alcohol providers within the state. Residential Treatment Facilities are reviewed on-site under federal guidelines. This unit coordinates with the DHS Office of Mental Health and Substance Abuse Services and the DHS Office of Children, Youth and Families to provide education regarding the quality of care, safety, and medical necessity. Referrals are researched and reviewed for possible fraud and abuse.
The Home and Community Based Services Section reviews Home Health services to evaluate compliance with state and federal laws and regulations. This process includes the review of providers, recipients, caregivers, and employees to determine if services were rendered and medically necessary and if quality care was provided.
The Medical Services Support Section reviews Durable Medical Equipment, Laboratory and Physical/Occupational Therapy, and Hospice provider services to evaluate compliance with state and federal laws and regulations. This process includes the review of providers, recipients, caregivers, and employees to determine if services were rendered and medically necessary and if quality care was provided.
Division of Program and Provider Compliance
The Division of Program and Provider Compliance (DPPC) identifies, reviews, and investigates cases of fiscal and programmatic abuse of the MA program under the fee for service and managed care delivery systems. DPPC is responsible for conducting a review of complaints, tips and referrals and for handling self-audits submitted for the specific provider types reviewed within DPPC. The division enforces state and federal regulations and policies, imposes administrative sanctions, and provides education to the involved providers. The process also includes civil and criminal referrals to other state offices, licensing bodies, and law enforcement agencies.
The sections within this division are:
Hospital-Based Services Section
Practitioner and Recipient Review Section
School-Based Access, Ambulance, and Pharmacy Review Section
The Hospital-Based Services Section is responsible for the review of inpatient acute care hospitals, rehabilitation facilities, and hospital-based services, including clinics, inpatient laboratory, special procedure units, and emergency room services. The reviews include the evaluation for appropriate coding, APR DRG assignment, medical necessity, level of care, and quantity/quality of care.
The Practitioner and Recipient Review Section reviews practitioner services, including physicians, dentists, chiropractors, podiatrists, optometrists, and outpatient clinics. In addition, this section administers the Recipient Restriction/Centralized Lock-in Program for fee for service and managed care recipients who are identified as overusing and/or misusing MA services. The restriction process involves an evaluation of the degree of abuse, a determination as to whether or not the recipient should be restricted, notification of the restriction, and evaluation of subsequent MA services. A recipient placed in this program is restricted to obtaining certain services from a single provider of his/her choice. Restrictions are lifted after a period of five years if improvement in use of services is demonstrated.
The School-Based Access, Ambulance and Pharmacy Review Section ensures enrolled MA Pharmacy, Ambulance and School-Based providers render quality services in accordance with state and federal rules and regulations, apply administrative sanctions, and refers cases of potential fraud to the appropriate enforcement agency.
Program Support and Analysis Unit
This unit administers the MA Provider Compliance Hotline, coordinates and manages provider complaints, initiates mandated preclusion actions, works special project and is the technical liaison for the bureau.
Integrity Management Section
Managed Care Organization Section
Referral and Program Support Section
The Integrity Management Section is the primary interface between BPI and the Provider Reimbursement and Operations Management Information System (PROMISe) in electronic format. This unit maintains the Fraud and Abuse Detection System (FADS), extracts data for use in case investigations, and can or may conduct statistically valid random sampling when provider overpayments are identified by BPI review staff. This section is also responsible for the preclusion of MA providers, individuals and entities who are then excluded from rendering, ordering, or arranging for services for MA recipients.
The Managed Care Organization (MCO) Section coordinates referrals from MCOs, reviews fraud and abuse programs of MCOs under contract to DHS, and participates in core teams that monitor the MCOs.
The Referral and Program Support Section works on special projects, analyzes data to identify future reviews, and is the technical liaison for the bureau vendor programs.
Division of Third Party Liability
The Division of Third Party Liability (TPL) manages the federally mandated cost containment program designed to identify, enforce the use of and recover from third party benefits available to MA recipients, and administers the Estate Recovery Program and the Health Insurance Premium Payment (HIPP) Program.
These activities are governed by the following
PA Code Regulation
: Chapter 1101.64. Third-party medical resources (TPR)
Casualty Recoveries
Estate Recovery Program
Recovery Section
Claims Investigation Agent and TPL Program Investigator Units: These units are responsible for recovering cash and MA claims against liable third parties, recipients and probated estates. The Estate Recovery Program enables the commonwealth to recover from the probate estate of individuals who were fifty-five (55) years of age or older at the time assistance was received for Long-Term Care or Home and Community-Based services.
Health and Medicare Unit: The primary function of the unit is to ensure that all available health insurance resources are utilized for payment of claims for all MA eligible recipients.
Statement of Claims (SOC) Creation Unit: This unit has the responsibility to provide statements of claim for all personal injury and estate recovery claim requests.
Financial Accountability Unit: This unit processes, tracks and reports on all financial transactions performed within TPL. HIPP Program and MA for Workers with Disabilities (MAWD) program payments are received, recorded and deposited by the unit.
Support Unit: This unit provides all clerical support to the division. It is responsible for the initial review of all new mail/faxes and making independent decisions to open a case or send a "No Recovery" letter.
Program Management Section
Application Management Unit:
The Application Management Unit is responsible for developing, monitoring and maintaining all TPL systems, applications and databases. This unit is responsible for procuring and installing all new PCs, site security, administration, and troubleshooting PC/data problems. The Unit is also responsible for establishing/monitoring all data exchange contracts with TPL and the monitoring of the contingency fee recovery contractor for TPL.
Resource Management Unit: The Resource Management Unit is responsible for maintaining the integrity of the TPL data on the Client Information System (CIS) so that resources in CIS can be used in the claims processing system (PROMISe) for cost avoidance and recovery activities. This includes developing system requirements, testing and monitoring the revised logic and communicating the information to the county assistance offices, headquarters staff and business partners as necessary. This unit also monitors data exchanges with insurance carriers, which adds and updates TPL resource information. Another main responsibility of this unit is to ensure all the cost avoidance functions are correct in PROMISe.
Health Insurance Premium Payment (HIPP) Program Section
The Omnibus Budget Act of 1990 (OBRA '90) required all states to enact a program to identify Medicaid recipients with access to medical insurance through employment, and to evaluate the cost-effectiveness of enrolling those recipients into private health insurance.
The HIPP Program reviews the cost-effectiveness of employer group health plans and enrolls eligible MA recipients into employer group health insurance when it is determined to be cost-effective.
The HIPP Program also assists in administrating MAWD and the Breast and Cervical Cancer Prevention and Treatment (BCCPT) programs.
The HIPP Program tracks and reports premium payments for individuals determined eligible for the MAWD program by the County Assistance Office.
For more information on the MAWD program
The HIPP Program provides technical support to the County Assistance Office by reviewing the applicant's existing insurance policy and determining "creditable coverage" as defined by the Health Insurance Portability and Accountability Act (HIPAA).
For more information on the BCCPT Program
TPL Contact List
PROGRAM AREA
CONTACT
PHONE
(Area Code 717)
Breast and Cervical Cancer Prevention and
Treatment Program Referrals
Questions about creditable coverage
of the recipient's health plan.
Veronica Ressler
Daron Morrill
772-6744
772-6370
Casualty Recovery, including Special Needs
Trusts, TCT (Trauma Code Tracking)/
Medical Service Questionnaires
Questions about the TCT/Medical Services
questionnaire recipients receive to establish liability
or the establishment of special needs trusts.
Alexander Angstadt
Desiree Ross
772-6254
772-6023
Estate Recovery
Questions about estate recovery from family members of the
deceased recipient – contact TPL.
Questions from active recipients and/or their family about how
estate recovery might affect a future estate – refer to a legal/financial advisor.
Desiree Ross
David Hetrick
Christina Faye
772-6023
772-4600
214-1869
HIPP (Health Insurance Premium Payment) Program
Questions about the employer group health
insurance plan in which a recipient is enrolled.
Veronica Ressler
Tara Gilligan
Desha Fawber
772-6744
272-214-3133
705-8134
Insurance Recoveries (Medicare and Commercial)
Questions from providers regarding recipient eligibility
or other insurance coverage on the date of service.
Ebonne Davis
705-8278
LTC Policies
Questions to determine how LTC benefits should
be paid, i.e. to the recipient or a family member.
Ebonne Davis
705-8278
Spousal Annuities
Questions about spousal annuities
other than eligibility concerns.
Vince Porter
772-6233
TPL Resources
Questions on how information should be entered
on TPL and what information should be included.
Sean Bloom
705-9702
TPL Contractor
Questions about recoveries completed by BRSi.
Amber Cook
Charles Williams
772-6247
214-1238
Managed Care
Questions involving managed care plans with TPL issues.
Rebekah Leiphart
346-3099