- Behavioral Health Review Section
- School-Based Access, Ambulance, and Pharmacy Review Section
- Integrity Management Section
- MCO Section
- Hospital-Based Services Section
- Practitioner/Recipient Restriction Section
- Home and Community Based Services Section
- Medical Services Support Section
- Recovery Section
- Claims Investigation Agent Unit
- TPL Program Investigator Unit
- Health and Medicare Unit
- Statement of Claim (SOC) Creation Unit
- Financial Accountability Unit
- Support Unit
- Applications Management Unit
- Resource Management Unit
- HIPP Policy Unit
- HIPP Operations Unit
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 MCOs under contract to DHS.
The sections within this division are:
- Integrity Management Section
- Behavioral Health Review Section
- School-Based Access, Ambulance, and Pharmacy Review Section
- MCO Section
The Integrity Management Section is the primary interface between BPI and the Provider Reimbursement and Operations Management Information System (PROMISe) in electronic format. 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. This section is also responsible for the preclusion of MA providers, individuals and entities who are then excluded from rendering, ordering, or arranging for services for MA recipients.
The Behavioral Health Review Section is responsible for the review and oversight of all mental health, developmental disabilities, and drug and alcohol providers within the state. Residential Treatment Facilities are reviewed on-site under federal guidelines. This unit coordinates with the DHS Office of Mental Health and Substance Abuse Services and the DHS Office of Children, Youth and Families to provide education regarding the quality of care, safety, and medical necessity. Referrals are researched and reviewed for possible fraud and abuse.
The School-Based Access, Ambulance and Pharmacy Review Section ensures enrolled MA Pharmacy, Ambulance and School-Based providers render quality services in accordance with state and federal rules and regulations, apply administrative sanctions, and refers cases of potential fraud to the appropriate enforcement agency.
The MCO Section coordinates referrals from MCOs, reviews fraud and abuse programs of MCOs under contract to DHS, and participates in core teams that monitor the MCOs.
This division also administers the MA Provider Compliance Hotline, coordinates and manages provider complaints, and initiates mandated preclusion actions.
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 and managed care delivery systems. DPPC is responsible for conducting a review of complaints, tips and referrals and for handling self-audits submitted for the specific provider types reviewed within DPPC. The division enforces state and federal regulations and policies, imposes administrative sanctions, and provides education to the involved providers. The process also includes civil and criminal referrals to other state offices, licensing bodies, and law enforcement agencies.
The sections within this division are:
- Hospital-Based Services Section
- Practitioner and Recipient Review Section
- Home and Community Based Services Section
- Medical Services Support Section
The Hospital-Based Services Section is responsible for the review of inpatient acute care hospitals, rehabilitation facilities, and hospital-based services, including clinics, inpatient laboratory, special procedure units, and emergency room services. The reviews include the evaluation for appropriate coding, APR DRG assignment, medical necessity, level of care, and quantity/quality of care.
The Practitioner and Recipient Review Section reviews practitioner services, including physicians, dentists, chiropractors, podiatrists, optometrists, and outpatient clinics. In addition, this section administers the Recipient Restriction/Centralized Lock-in Program for fee for service and managed care recipients who are identified as overusing and/or misusing MA 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 MA 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 if improvement in use of services is demonstrated.
The Home and Community Based Services Section reviews Home Health services to evaluate compliance with state and federal laws and regulations. This process includes the review of providers, recipients, caregivers, and employees to determine if services were rendered and medically necessary and if quality care was provided.
The Medical Services Support Section reviews Durable Medical Equipment, Laboratory and Physical/Occupational Therapy, and Hospice provider services to evaluate compliance with state and federal laws and regulations. This process includes the review of providers, recipients, caregivers, and employees to determine if services were rendered and medically necessary and if quality care was provided.
Division of Third Party Liability
The Division of Third Party Liability (TPL) manages the federally mandated cost containment program designed to identify, enforce the use of and recover from third party benefits available to MA recipients, and administers the Estate Recovery Program and the Health Insurance Premium Payment (HIPP) Program.
These activities are governed by the following PA Code Regulation: Chapter 1101.64. Third-party medical resources (TPR)
- Casualty Recoveries
- Estate Recovery Program
Recovery Section
Claims Investigation Agent and TPL Program Investigator Units: These units are responsible for recovering cash and MA claims against liable third parties, recipients and probated estates. The Estate Recovery Program enables the commonwealth to recover from the probate estate of individuals who were fifty-five (55) years of age or older at the time assistance was received for Long-Term Care or Home and Community-Based services.
- Health and Medicare Unit: The primary function of the unit is to ensure that all available health insurance resources are utilized for payment of claims for all MA eligible recipients.
- Statement of Claims (SOC) Creation Unit: This unit has the responsibility to provide statements of claim for all personal injury and estate recovery claim requests.
- Financial Accountability Unit: This unit processes, tracks and reports on all financial transactions performed within TPL. HIPP Program and MA for Workers with Disabilities (MAWD) program payments are received, recorded and deposited by the unit.
- Support Unit: This unit provides all clerical support to the division. It is responsible for the initial review of all new mail/faxes and making independent decisions to open a case or send a "No Recovery" letter.
Program Management Section
- Application Management Unit: The Application Management Unit is responsible for developing, monitoring and maintaining all TPL systems, applications and databases. This unit is responsible for procuring and installing all new PCs, site security, administration, and troubleshooting PC/data problems. The Unit is also responsible for establishing/monitoring all data exchange contracts with TPL and the monitoring of the contingency fee recovery contractor for TPL.
- Resource Management Unit: The Resource Management Unit is responsible for maintaining the integrity of the TPL data on the Client Information System (CIS) so that resources in CIS can be used in the claims processing system (PROMISe) for cost avoidance and recovery activities. This includes developing system requirements, testing and monitoring the revised logic and communicating the information to the county assistance offices, headquarters staff and business partners as necessary. This unit also monitors data exchanges with insurance carriers, which adds and updates TPL resource information. Another main responsibility of this unit is to ensure all the cost avoidance functions are correct in PROMISe.
Health Insurance Premium Payment (HIPP) Program Section
The Omnibus Budget Act of 1990 (OBRA '90) required all states to enact a program to identify Medicaid recipients with access to medical insurance through employment, and to evaluate the cost-effectiveness of enrolling those recipients into private health insurance.
The HIPP Program reviews the cost-effectiveness of employer group health plans and enrolls eligible MA recipients into employer group health insurance when it is determined to be cost-effective.
The HIPP Program also assists in administrating MAWD and the Breast and Cervical Cancer Prevention and Treatment (BCCPT) programs.
The HIPP Program tracks and reports premium payments for individuals determined eligible for the MAWD program by the County Assistance Office. For more information on the MAWD program.
The HIPP Program provides technical support to the County Assistance Office by reviewing the applicant's existing insurance policy and determining "creditable coverage" as defined by the Health Insurance Portability and Accountability Act (HIPAA). For more information on the BCCPT Program.
TPL Contact List
PROGRAM AREA
PHONE
(Area Code 717)Breast and Cervical Cancer Prevention and
Treatment Program Referrals:
Questions about creditable coverage
of the recipient's health plan.Veronica Ressler
Daron MorrillCasualty Recovery, including Special Needs
Trusts, TCT (Trauma Code Tracking)/
Medical Service Questionnaires:
Questions about the TCT/Medical Services
questionnaire recipients receive to establish liability
or the establishment of special needs trusts.Alexander Angstadt
Desiree RossEstate Recovery:
Questions about estate recovery from family members of the
deceased recipient – contact TPL.
Questions from active recipients and/or their family about how
estate recovery might affect a future estate – refer to a legal/financial advisor.Desiree Ross
David Hetrick
Christina Faye772-6023
772-4600
214-1869HIPP (Health Insurance Premium Payment) Program:
Questions about the employer group health
insurance plan in which a recipient is enrolled.Veronica Ressler
Tara Gilligan
Desha Fawber772-6744
272-214-3133
705-8134Insurance Recoveries (Medicare and Commercial):
Questions from providers regarding recipient eligibility
or other insurance coverage on the date of service.LTC Policies:
Questions to determine how LTC benefits should
be paid, i.e. to the recipient or a family member.Spousal Annuities:
Questions about spousal annuities
other than eligibility concerns.TPL Resources:
Questions on how information should be entered
on TPL and what information should be included.TPL Contractor:
Questions about recoveries completed by BRSi.Amber Cook
Charles WilliamsManaged Care:
Questions involving managed care plans with TPL issues.