Indiana Medicaid Surveillance, Utilization Review, and Pharmacy Audits
Since 1998, Health Care Excel (HCE) has been the Surveillance and Utilization Review (SUR) contractor for the Indiana Office of Medicaid Policy and Planning (OMPP). The OMPP is part of the Indiana Family and Social Services Administration (FSSA). The Indiana Medicaid program is currently known as the Indiana Health Coverage Programs (IHCP).
The SUR team generates profiles of health care
delivery and utilization patterns of health care providers and Medicaid
members that are based on user-defined parameters and other guidelines. By
analyzing and comparing providers to their respective peer groups, abnormal
practices may be identified. Appropriate action can then be initiated to
address the findings.
SUR staff members identify aberrant providers, conduct hospital and
non-hospital audits, educate providers on program guidelines, and recover
inappropriately reimbursed funds through the management of the following SUR
components.
- Program Integrity (PI): HCE maintains a Member and Provider
Concerns line that allow individuals to report suspected cases of
program abuse. PI staff members review all allegations of abuse for
appropriate action, which may include referrals to conduct on-site or
medical record audits. PI works in collaboration with a variety of
regulatory agencies that include but are not limited to the Medicaid
Fraud Control Unit, Medicare Program Safeguard Contractors, and The
Office of Inspector General (OIG) for more comprehensive investigations.
- Provider Research Team: HCE’s SUR research team enhances
identification strategies and expands development of the initial case
review process by ensuring that the most aberrant providers receive
concentrated auditing efforts.
- Provider Audit Team: The audit team focuses on conducting
on-site and medical record audits and compilation of findings. This team
is primarily responsible for external written and verbal correspondence
with providers regarding the overall audit process. In addition, this
team prepares reports and recommendations subsequent to provider audits.
Audit staff work closely with the provider community to conduct audits
and provide education.
- Claims Analysis and Recovery (CAR): HCE’s CAR program reviews
claims data at the systems level. The process determines aberrant
billing patterns and inappropriate reimbursements that may be occurring
across a specific provider type or specialty. When a potential issue is
discovered, CAR staff members perform extensive research and conduct
payment studies to determine if an overpayment has occurred. If a
medical record audit is necessary to verify the validity of payment, the
case is referred for a SUR audit.
- Prepayment Review (PPR): HCE’s PPR team verifies that claim
information submitted for Medicaid reimbursement contain supporting
documentation indicating services were provided as presented on the
claim prior to payment. Providers that demonstrate a pattern of abnormal
billing practices are placed on PPR for a given period of time. Once the
provider has demonstrated compliance with billing guidelines, PPR may be
rescinded.
- Recoupment: HCE’s recoupment function ensures the collection and monitoring of provider overpayments that are retrospectively identified through on-site and medical record audits. This procedure allows for the recovery of inappropriately paid Medicaid dollars. A calculation of interest accrual is completed on all provider overpayments.
