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May 1, 2012 - April 30, 2013
The mission of the Bureau of Program Integrity is to ensure that:
This bureau is comprised primarily of medical professionals responsible for preventing, detecting, deterring, and correcting fraud, abuse, and wasteful practices by providers of medical assistance services, including managed care organizations, applying administrative sanctions, and referring cases of potential fraud to the appropriate enforcement agency. This responsibility includes evaluating services rendered by medical providers and managed care organization 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.
To report suspected fraud or abuse of services provided under the Medical Assistance Program, please call the Bureau of Program Integrity at 1-866-DPW-TIPS (1-866-379-8477) or write to us at:
Department of Public Welfare
Office of Medical Assistance Programs
Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675
Additional information about Medical Assistance Fraud and Abuse can be found in the Fraud and Abuse section of this Web site. There you can click on The MA Provider Compliance Hotline: Response Form to report potential fraud and abuse.
Program Integrity Organization:
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 managed care organizations under contract to the Department.
The Information Technology/Data Support Unit is the primary interface between BPI and the Provider Reimbursement and Operations Management Information System in electronic format (PROMISe). This Unit maintains the Fraud and Abuse Detection System (FADS), extracts data for use in case investigations, and conducts statistically valid random sampling when provider overpayments are identified by BPI review staff.
The Managed Care Unit coordinates referrals from managed care organizations, reviews fraud and abuse programs of managed care organizations under contract to the Department, and participates on core teams that monitor the managed care organizations.
The Sections and Units within this Division are:
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 environment or by providers with managed care organizations under contract to the Department. DPPC also is responsible for the Diagnosis Related Group Validation Review Project and for handling self audits submitted by specific provider types reviewed within the Division's sections.
In addition, DPPC administers the Recipient Restriction/Centralized Lock-in Program for fee for service and managed care recipients who are identified as overusing and/or misusing medical assistance 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 medical assistance 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 (per current CMS regulations) if improvement in use of services is demonstrated.
This Division also administers the MA Provider Compliance Hotline, coordinates and manages provider complaints, and initiates mandated preclusion actions.
The Sections within this Division are: