Bureau of Program Integrity

​Overview

The Bureau of Program Integrity (BPI) ensures Medical Assistance (MA) recipients receive quality medical services and that MA recipients do not abuse their use of medical services; applies administrative sanctions; refers cases of potential fraud to the appropriate enforcement agency; and evaluates medical services rendered by medical providers and managed care organization (MCO) provider networks. The bureau monitors MA recipient overuse and abuse of medical services; maintains ongoing working relationships with federal and state enforcement agencies involved in monitoring potential health care fraud and abuse and ensures feedback is provided to the Department of Human Services (DHS) to enhance program performance. The bureau manages the federally mandated cost containment program designed to identify the use of, and recovery from, third party benefits available to MA recipients, and administers the Estate Recovery Program and the Health Insurance Premium Payment (HIPP) Program.

Bureau staff include medical professionals responsible for preventing, detecting, deterring, and correcting fraud, abuse and wasteful practices by providers of MA services, including MCOs; applying administrative sanctions; and referring cases of potential fraud to the appropriate enforcement agency. This responsibility includes evaluating services rendered by medical providers and MCO 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.

Program Integrity Organization:

• Administrative Unit
• Division of Provider Review
  • Behavioral Health Review Section
  • Home and Community Based Services Section
  • Medical Services Support Section
• Division of Program and Provider Compliance
  • Hospital-Based Services Section
  • Practitioner/Recipient Restriction Section
  • School-Based Access, Ambulance, and Pharmacy Review Section
• Program Support and Analysis Unit
  • Integrity Management Section
  • Managed Care Organization Section
  • Referral and Program Support Section

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:

• Behavioral Health Review Section
• Home and Community Based Services Section
• Medical Services Support Section

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 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 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
• School-Based Access, Ambulance, and Pharmacy Review 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 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.

Program Support and Analysis Unit

This unit administers the MA Provider Compliance Hotline, coordinates and manages provider complaints, initiates mandated preclusion actions, works special project and is the technical liaison for the bureau.

• Integrity Management Section
• Managed Care Organization Section
• Referral and Program Support 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 Managed Care Organization (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.

The Referral and Program Support Section works on special projects, analyzes data to identify future reviews, and is the technical liaison for the bureau vendor programs.

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