NC DHHS: Employee Newsletter

Announces Crackdown on Fraud and Abuse

Division of Medical Assistance Director Dr. Allen Dobson has outlined a seven point plan for the division during 2005-07, central to that plan is a new initiative to improve accountability.

Dr. Dobson said that he was reorganizing existing staff to create a unit that will assist current program integrity staff in investigating potential abuse, and strengthening actions against providers who commit fraud and abuse and requiring providers who enroll in the program to provide more information about past problems.

“We have to ensure that every Medicaid dollar is well spent,” Dr. Dobson said. “The taxpayers of this state need to know that we are taking waste seriously. Medicaid fraud and abuse isn’t a victimless crime. You and I – the taxpayers – are the victims. Children, the elderly and people with disabilities who get substandard care because of fraud and abuse are also victims.”

Dr. Dobson said the new unit will determine what services and costs are reasonable. “We will identify the outliers, providers whose numbers just don’t match what an average provider is doing across the state,” he explained. “We will personally visit those providers and see what is going on in their offices. It is our duty to investigate when things don’t look right. We will catch fraud and abuse, and we will also improve quality of care.”

Staff will be moved from other sections of the Division of Medical Assistance to create the new ten person unit.

In addition to the new unit, the Division is also going to institute new steps in handling fraud and abuse. “Currently, we refer fraud and abuse cases to the Attorney General’s office for potential criminal charges and we also recoup inappropriate payments made to providers,” he said. “But, while that investigation is underway the provider continues to provide care and receive Medicaid payments. We’re going to immediately suspend Medicaid payments and Medicaid enrollment to providers that are found by an administrative review and hearing to have committed fraud and abuse warranting referral to the Attorney Generals office. These are sticks that we need to ensure that providers understand that if you commit fraud and abuse with North Carolina Medicaid, then the punishment is going to be severe and swift.”

The division will also start asking providers if they have ever been sued, sanctioned by another insurer, or had actions taken against them by a licensing board in order to ensure better quality of services. “This is standard practice among private insurers,” Dr. Dobson said. “It must be our standard operating procedure as well.”

Other key points of the plan are:

Budgetary Control- Successfully reduce costs and exceed budgetary targets each year.

Management rather than Regulation- Establish a culture of proactive healthcare management rather than a pure regulatory function for the division.

Quality Improvement- Improve the care provided to Medicaid patients by reducing variability and promoting best practice standards by using & expanding Community Care of North Carolina.

Customer Service- Define DMA customers and strive to meet or exceed agreed upon expectations.

Public Image- Improve the public image of the division and the Medicaid program.

Job Satisfaction- Make the division a great place to work and find ways to reward employees.

Last Modified: February 4, 2013 .

Home Site Map Divisions and Offices Contact Us Search DHHS:

	The August 2005 newsletter, print version Use this version to print and distribute the newsletter. It is in Adobe Acrobat. If you don't have the Adobe Acrobat Reader, download it for free. Past Issues
	The August 2005 issue, online version.
	New DMA Director Outlines Goals for 2005-2007: Division of Medical Assistance Director Dr. Allen Dobson has outlined a seven point plan for the division during 2005-07, central to that plan is a new initiative to improve accountability.	Dr. Leah Devlin Elected President of National Public Health Association: State Health Director Leah Devlin been elected President of the Association of State and Territorial Health Officials (ASTHO). ICCHP Members Sworn In ¡Salud y Saludos!: With more than 100,000 mostly Latino farm workers working the fields in North Carolina, and with tens of thousands of others working in outdoor jobs, it may be surprising there aren’t more accidents involving the bad weather.
	Thurman named GMS Director
	NC Medicaid Drug Rebate Program Rated one of the Best in Nation Protect Yourself from Heat Danger Public Health getting a new home this Summer High appointed to Serve as Mentor	New Hospital Construction Clinical director appointed at Broughton Massive survey results in sanctions against 106 group homes Adoption Profile


	New DMA Director Outlines Goals for 2005-2007 Announces Crackdown on Fraud and Abuse Division of Medical Assistance Director Dr. Allen Dobson has outlined a seven point plan for the division during 2005-07, central to that plan is a new initiative to improve accountability. Dr. Dobson said that he was reorganizing existing staff to create a unit that will assist current program integrity staff in investigating potential abuse, and strengthening actions against providers who commit fraud and abuse and requiring providers who enroll in the program to provide more information about past problems. “We have to ensure that every Medicaid dollar is well spent,” Dr. Dobson said. “The taxpayers of this state need to know that we are taking waste seriously. Medicaid fraud and abuse isn’t a victimless crime. You and I – the taxpayers – are the victims. Children, the elderly and people with disabilities who get substandard care because of fraud and abuse are also victims.” Dr. Dobson said the new unit will determine what services and costs are reasonable. “We will identify the outliers, providers whose numbers just don’t match what an average provider is doing across the state,” he explained. “We will personally visit those providers and see what is going on in their offices. It is our duty to investigate when things don’t look right. We will catch fraud and abuse, and we will also improve quality of care.” Staff will be moved from other sections of the Division of Medical Assistance to create the new ten person unit. In addition to the new unit, the Division is also going to institute new steps in handling fraud and abuse. “Currently, we refer fraud and abuse cases to the Attorney General’s office for potential criminal charges and we also recoup inappropriate payments made to providers,” he said. “But, while that investigation is underway the provider continues to provide care and receive Medicaid payments. We’re going to immediately suspend Medicaid payments and Medicaid enrollment to providers that are found by an administrative review and hearing to have committed fraud and abuse warranting referral to the Attorney Generals office. These are sticks that we need to ensure that providers understand that if you commit fraud and abuse with North Carolina Medicaid, then the punishment is going to be severe and swift.” The division will also start asking providers if they have ever been sued, sanctioned by another insurer, or had actions taken against them by a licensing board in order to ensure better quality of services. “This is standard practice among private insurers,” Dr. Dobson said. “It must be our standard operating procedure as well.” Other key points of the plan are: Budgetary Control- Successfully reduce costs and exceed budgetary targets each year. Management rather than Regulation- Establish a culture of proactive healthcare management rather than a pure regulatory function for the division. Quality Improvement- Improve the care provided to Medicaid patients by reducing variability and promoting best practice standards by using & expanding Community Care of North Carolina. Customer Service- Define DMA customers and strive to meet or exceed agreed upon expectations. Public Image- Improve the public image of the division and the Medicaid program. Job Satisfaction- Make the division a great place to work and find ways to reward employees.

	Last Modified: February 4, 2013 .

The August 2005 newsletter, print version

Past Issues

The August 2005 issue, online version.

New DMA Director Outlines Goals for 2005-2007

Announces Crackdown on Fraud and Abuse