Report Fraud, Waste and Abuse

Peach State Health Plan takes the detection, investigation, and prosecution of waste, fraud, and abuse very seriously. It operates a Fraud Waste Abuse program that complies with all state and federal laws. Peach State Health Plan's management company, Centene Corporation, successfully operates a Special Investigations Unit that mines claims data for upcoding, unbundling, and other systematic deviations that suggest fraudulent or abusive billing practices and investigates all reports of waste, fraud, and abuse. Peach State Health Plan's Compliance Department and Centene’s Special Investigations Unit work very closely with the Department of Community Health and the Georgia Medicaid Fraud Control Unit in prosecuting substantiated instances of health care fraud.

If you suspect or witness health care fraud committed by a provider, member, or employee, please call Peach State Health Plan's anonymous and confidential hotline at (866) 685-8664.

Authority and Responsibility 

Peach State Health Plan is committed to identifying, investigating, and prosecuting those who commit health care fraud. Peach State Health Plan's Vice President of Compliance has overall responsibility and authority for carrying out the provisions of the compliance and WAF programs.

Post-Processing Claim Audits

Background

Peach State Health Plan (Peach State) is contractually obligated to have procedures in place to detect waste, fraud, and abuse. This is achieved through:

  • Claims editing
  • Post-processing review of claims
  • Provider profiling and credentialing
  • Quality control
  • Utilization management 

As accountable and fiscally responsible stewards of public funds, we take the prevention and detection of waste, fraud, and abuse very seriously.  Peach State has a management contract with its parent organization, Centene Corporation (Centene) in which Centene conducts routine post-processing claims audits on behalf of Peach State.  These audits are designed to ensure that billing codes and practices are correct and that Peach State has paid health care providers appropriately.  In addition to provider reviews, Centene also investigates members who appear to be abusing the Medicaid and PeachCare for Kids® programs. 

Post Processing Claims Audit

A post-processing claims audit consists of a review of clinical documentation and claims submissions to determine whether the payment made was consistent with the services rendered. To start the audit, Centene Auditors request medical records for a defined review period.  Providers have two weeks to respond to the request; if no response is received, a second and final request for medical records is forwarded to the provider.  If the provider fails to respond to the second and final request for medical records, or if services for which claims have been paid are not documented in the medical record, Peach State will recover all amounts paid for the services in question. 

Centene Auditors review cases for potential unbundling, upcoding, mutually exclusive procedures, incorrect procedures and/or diagnosis for member’s age, duplicates, incorrect modifier usage, and other billing irregularities. They consider state and federal laws and regulations, provider contracts, billing histories, and fee schedules in making determinations of claims payment appropriateness. If necessary, a clinician of like specialty may also review specific cases to determine if billing is appropriate. Auditors issue an audit results letter to each provider upon completion of the audit, which includes a claims report which identifies all records reviewed during the audit. If the Auditor determines that clinical documentation does not support the claims payment in some or all circumstances, Peach State will seek recovery of all overpayments. 

Depending on the number of services provided during the review period, Peach State may calculate the overpayment using an extrapolation methodology.  Extrapolation is the use of statistical sampling to calculate and project overpayment amounts.  It is used by Medicare Program Safeguard Contractors, CMS Recovery Audit Contractors, and Medicaid Fraud Control Units in calculating overpayments, and is recommended by the OIG in its Provider Self-Disclosure Protocol (63 Fed. Reg. 58,399; Oct. 30, 1998).  To ensure accurate application of the extrapolated methodology, Centene uses RAT-STATS 2007 Version 2, the OIG’s statistical software tool, to select random samples, assist in evaluating audit results, and calculate projected overpayments.  

Providers who contest the overpayment methodology or wish to calculate an exact overpayment figure may request a full, on-site chart audit of all services rendered during the review period.  A full chart audit may take four to eight weeks to complete.  On-site audits are performed by Peach State’s contracted vendor, HMS.  Per the terms of your contract, you may be liable for the cost of an on-site audit.      

Audit findings are reported to the Department of Community Health and may also be reported to the Georgia Healthcare Fraud Control Unit.

Additional information regarding Peach State’s Waste, Fraud, and Abuse program may be found in the Provider Manual.  To report wasteful, abusive, or fraudulent activity, please contact Peach State’s Confidential Hotline at 1-866-685-8664.