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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.

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