Overview
The Office of Quality Assurance (“QA”) is responsible for ensuring the fiscal and programmatic integrity of programs administered by the Department of Social Services (“Department”). In addition, QA is responsible for ensuring the integrity of administrative functions of the Department. QA has five separate divisions, each with unique program integrity functions: Audit, Investigations and Recoveries, Special Investigations, Quality Control and Third Party Liability.
The Audit Division ensures compliance, efficiency, and accountability within federal and state programs administered by the Department by detecting and preventing mismanagement, waste and program abuse and ensuring that state and federal dollars are spent appropriately, responsibly, and in accordance with applicable laws and regulations. To achieve this objective, The Audit Division:
- Performs federally mandated audits of medical and health care providers that are paid through the various medical assistance programs administered by the Department;
- Reviews medical provider activities, audits claims, identifies overpayments, and educates providers on program integrity issues;
- Provides support and assistance to the Department Special Investigations Division in the ongoing effort to combat fraud and abuse;
- Performs audits of the Department’s operations, involving review of administrative and programmatic functions and the electronic data processing systems used in their support;
- Coordinates the Department’s responses to all outside audit organizations reviews performed on the Department, including but not limited to, the State Auditors of Public Accounts and federal audit organizations;
- Reviews federal and state single audit reports and performs audits of financial, administrative and programmatic functions of the Department’s grantees;
- Performs data analytics to identify aberrant billing activity and pursues collection of such overpayments; and
- Substantiates whether complaints received from various sources are valid and determines the proper disposition of the complaint including conducting an audit or forwarding to the Department’s Special Investigations Division.
Self Audits
The Mission of the Office of Quality Assurance (QA) is to maximize the resources available to families and individuals that need assistance by assuring quality, accuracy, efficiency and effectiveness in the delivery of DSS programs. This mission is accomplished by ensuring that: adequate internal controls are in place and functioning; fraud is deterred and pursued; and overpayments to providers and clients are reduced or recouped; and unnecessary costs are avoided.
QA is committed to detecting potential fraud, waste and abuse within the state’s Medicaid program and recovering inappropriate payments. As part of our multi-disciplinary approach to attaining these goals, we are making a concerted effort to recognize providers who find problems within their own organizations, reveal (self-disclose) those issues to QA, and refund inappropriate payments.
QA recognizes that many improper payments are discovered during the course of a provider’s internal review processes. While providers who identify that they have received inappropriate payments from the Medicaid program are obligated to return the overpayments we appreciate that it is essential to develop and maintain a fair, reasonable process that will be mutually beneficial for both the State of Connecticut and the provider involved. QA has developed this approach to encourage providers to investigate and report matters that involve possible fraud, waste, abuse or inappropriate payment of funds—whether intentional or unintentional—under the state’s Medicaid program. By forming a partnership with providers through this self-disclosure approach, QA’s overall efforts to eliminate fraud, waste and abuse will be enhanced, while simultaneously offering providers a mechanism or method to reduce their legal and financial exposure.
Once a provider makes the determination to disclose a problem, the following steps should be followed:
At a minimum, gather the following information:
- The basis for disclosure, including how it was discovered, the time-period covered, and an assessment of the potential financial impact;
- The Medicaid program rules potentially implicated;
- Any corrective action taken to address the problem leading to the disclosure, the date the correction occurred and the process for monitoring the issue to prevent reoccurrence; and
- The name and telephone number(s) of the individual making the report on behalf of the provider.
- A summary of the identified underlying cause of the issue(s) involved and any corrective action taken.
- Detailed list of claims paid that comprise the overpayments (in an electronic medium and preferably in an Excel spreadsheet format). Each claim should list the billing provider Medicaid ID number, client name and Medicaid ID, dates of service(s), rates or procedure codes, the amount(s) paid by Medicaid and the corrected amounted.
- Contact QA with the above information:
Department of Social Services
Office of Quality Assurance
Attention: Cathie Bussolotta
55 Farmington Avenue
Hartford, CT 06105
860-424-5998
Cathie.Bussolotta@ct.gov
QA will determine the most appropriate resolution and the best mechanism to achieve resolution. All provider self-disclosures are subject to a thorough QA review to determine whether the amount identified is accurate. While repayment is encouraged/accepted as early in the process as possible, and any repayment will be credited toward the final settlement amount, QA will not accept money as full and final payment for self-disclosures prior to finalizing the review.
Following the review, QA staff will consult with the provider to establish a repayment amount. Once a repayment amount has been established, assuming full repayment has not previously been made, QA expects the provider to reimburse the State of Connecticut for the overpayment with a check for the full amount, made payable to the Connecticut Department of Social Services or enter into a repayment agreement. Repayments can occur through monthly payments to QA or by having QA withhold a portion of that provider’s bi-weekly reimbursement.
The Investigations and Recoveries Division is comprised of two units; the Client Investigations Unit and the Resources and Recoveries Unit. Both units have investigation staff located at both central and field office locations.
•Client Investigations Unit investigates alleged client fraud in various programs administered by the Department. This unit performs investigations via pre-eligibility, post-eligibility and other fraud investigation measures that include, but are not limited to, data integrity matches with other state and federal agencies. This unit also oversees the toll-free Fraud Hotline 1-800-842-2155 that is available to the public to report situations where it’s perceived that a public assistance recipient, a provider, or a medical provider may be defrauding the state.•Resources and Recoveries Unit is charged with ensuring that the Department is the payer of last resort for the cost of a client’s care by detecting, verifying, and utilizing third-party resources; establishing monetary recoveries realized from liens, mortgages, and property sales; and establishing recoveries for miscellaneous overpayments.
The Special Investigations Division is comprised of two units; Provider Investigations and Provider Enrollment.
•Provider Investigations Unit is charged with the responsibility of coordinating and conducting activities to investigate allegations of fraud in the Connecticut Medical Assistance Program. When appropriate, credible allegations of fraud are referred to the Department’s law enforcement partners pursuant to a memorandum of understanding (MOU). Parties to the MOU are the Office of the Chief State’s Attorney, the Office of the Attorney General and the U.S. Department of Health and Human Services’ Office of the Inspector General. Each entity is responsible for independently investigating the Department’s referral to determine if a criminal and/or civil action is appropriate.•Provider Enrollment Unit is responsible for the review and approval of all provider enrollment and re-enrollment applications, on an on-going basis. This Unit also shares responsibility for ensuring federal and ACA requirements for provider enrollment are instituted and adhered to. Coordination of efforts between the Provider Investigations Unit and Provider Enrollment Unit strengthens Connecticut’s program integrity efforts.