Iowa Medicaid Enterprise
In
2003, the Iowa Department of Human Services (DHS) made the decision to
separate the State Medicaid System into nine components. All components of
the program are housed in one DHS facility, forming the Iowa Medicaid
Enterprise (IME).Health Care Excel (HCE) was awarded the IME Surveillance and Utilization Review Services (SURS) function, responsible for making sure that Medicaid providers are properly billing the Iowa Medicaid System.
Surveillance and Utilization Review
The SURS function provides profiles of health care delivery and utilization patterns of providers that are based on user-defined parameters and other guidelines. By analyzing and comparing providers with their peer groups, atypical practices can be identified. Appropriate action is initiated to address the findings.
SURS pursues the following objectives
- Monitor utilization to identify potentially inappropriate utilization of the State Medicaid programs.
- Investigate and take actions to correct inappropriate utilization of the State Medicaid program by its individual participants.
- Identify abusive practices of providers.
- Identify utilization trends and patterns and develop audits.
- Educate providers found to have abused or inappropriately used services under the State Medicaid program.
- Develop statistical profiles of health care delivery and utilization patterns by providers in various categories of services.
- Identify concerns in the level of care or quality of covered services that are funded by the State Medicaid program and make appropriate referrals.
For the Iowa Medicaid provider community, HCE’s intent is to provide a fair and correct utilization review and to take appropriate actions to minimize fraud, abuse, and waste.
