NCJ Number
66883
Date Published
1976
Length
58 pages
Annotation
INTENDED FOR INTERNAL STAFF USE, THE MANUAL DETAILS POLICIES AND PROCEDURES FOR DETECTING FRAUD OR ABUSE IN THE KENTUCKY MEDICAL ASSISTANCE PROGRAM.
Abstract
THE SURVEILLANCE AND UTILIZATION REVIEW SECTION WITHIN THE BUREAU FOR SOCIAL INSURANCE OF THE DIVISION FOR MEDICAL ASSISTANCE IS CHARGED WITH THE RESPONSIBILITY FOR VERIFYING CLAIMS BY SERVICE PROVIDERS, INVESTIGATING SUSPECTED CASES OF FRAUD, RECOVERING MONEY PAID IN CASES OF FRAUD OR ABUSE, AND REFERRING CASES OF FRAUD TO LAW ENFORCEMENT OFFICIALS. THE QUARTERLY QUALITY CONTROL AND UTILIZATION REVIEW REPORT THE PRIMARY RESOURCE IN THE DETECTION OF FRAUD OR ABUSE, IS A COMPUTER PRINTOUT, PUBLISHED AT 3-MONTH INTERVALS, WHICH CONTAINS ALL MEDICAL ASSISTANCE PROGRAM ACTIVITIES FOR WHICH PAYMENT HAS BEEN MADE. BASED ON THE PRINTOUT, THE SURVEILLANCE AND UTILIZATION REVIEW SECTION IDENTIFIES ALL VENDORS WHOSE ACTIVITIES SHOW SOME KIND OF ABNORMALITY OR IRREGULARITY. IN A SECONDARY SCREENING PROCESS, COMPUTER-GENERATED VENDOR HISTORIES ARE ANALYZED FOR SITUATIONS AND OCCURRENCES EXPLAINING THE VENDOR'S EXCEPTIONAL STATUS. VENDORS WHO HAVE BEEN IDENTIFIED AS POSSIBLE FRAUD OR ABUSE CASES ARE REFERRED TO THE MEDICAL ASSISTANCE FIELD REPRESENTATIVES FOR AN ONSITE REVIEW. IN CASES INVOLVING ABUSE, BUT NOT NECESSARILY FRAUD, THE VENDORS ARE REFERRED TO THE LOCAL PEER REVIEW COMMITTEE FOR AN INITIAL REVIEW. IN CASES OF SUSPECTED FRAUD, THE VENDOR IS REFERRED TO THE APPROPRIATE LAW ENFORCEMENT AGENCIES. THE MANUAL INCLUDES COPIOUS SUPPLEMENTARY MATERIALS INCLUDING FLOW CHARTS, LETTERS, REVIEW FORMS, AND SURVEILLANCE REPORTS.