1. Who is Public Consulting Group?
PCG is a contractor of the Division of Medical Assistance and we have been directed to perform
a post-payment review on your organization. Our involvement in this process was released in a
Medicaid bulletin from April 2010 (and made effective from 1/28/2010 forward). The following
was taken directly from the April 2010 bulletin:
Attention: Behavioral Health Care Providers
DHHS/DMA Program Integrity Contract with Public
Medicaid services are provided to recipients in all 100 North Carolina counties. In
accordance with 42 CFR Part 455, which sets forth requirements for a State fraud
detection and investigation program, DMA’s Program Integrity Section investigates
Medicaid providers when clinically suspect behaviors or administrative billing patterns
indicate potentially abusive or fraudulent activity.
The review of providers of community behavioral health services has presented unique
challenges. These challenges and the related volume of cases have resulted in a backlog
that requires immediate attention. Program Integrity is committed to initiating these
reviews and safeguarding against unnecessary or inappropriate use of Medicaid services
and against excess payments.
In accordance with 10A NCAC 22F.0202, a Preliminary Investigation shall be conducted
on all complaints received or aberrant practices detected, until it is determined that there
are sufficient findings to warrant a full investigation; or there is sufficient evidence to
warrant referring the case for civil and/or criminal fraud action; or there is insufficient
evidence to support the allegation(s) and the case may be closed.
Effective January 28, 2010, Public Consulting Group (PCG), will assist the DMA’s
Program Integrity Behavioral Health Review Section in eliminating the backlog of
cases and prospectively maintaining a steady state of case reviews, preventing a future
backlog of cases from accumulating. For assigned cases, PCG will absorb the full
scale of operations, beginning with the receipt of a case file, conducting the clinical
review, establishing a statistically valid claim review sample for review, and
extrapolating these findings to calculate the recoupment.
PCG will initiate contact with the provider, inform the provider of the post payment
review process requirements, and work closely with the provider and DMA. PCG will
advise the provider where and how to submit records for the review, and will address
provider questions regarding the post-payment review process. If the provider is out of
compliance, a recoupment letter shall be forwarded to the provider in the amount of the
overpayment. The provider will have reconsideration and appeals rights if the provider
does not agree with the findings of the review. Reconsideration and appeal rights
instructions will be sent out with the recoupment letter.
If the preliminary investigation supports the conclusion of possible fraud, the case shall
be referred to the appropriate law enforcement agency for a full investigation.
Program Integrity Behavioral Health Review Section
2. Why are you looking at my organization?
PCG is performing this review as directed by the Division of Medical Assistance. See above
(from April 2010 Medicaid bulletin) for more details concerning DMA’s directives.
3. I got a letter saying that I only have five days to upload documentation and I have never
received anything from you before.
PCG sends the initial medical records request (which gives agencies ten (10) business days for
uploading documentation) via certified mail to the physical or the accounting address as listed in
Medicaid. If you did not pick up your certified mail or if you are no longer located at the address
listed in Medicaid, then that mailing was returned to our Raleigh address.
In order to prevent your agency from not receiving our mailings, we encourage you to update
your mailing address as soon as possible with Medicaid. You can update your provider address
4. Do you want all of our documentation for all of our recipients?
We are only looking at the dates specified in the letter and we are only reviewing
documentation pertaining to the recipients specifically listed in the letter. The specific
date(s) which we are looking at are listed next to the recipient’s name on the letter.
5. How will I know if I need to send you any more documentation?
We will send you a follow-up letter once we have processed all of your documentation. This
letter will detail the recipient and personnel information which we have received. In order to
view all of the documentation which we have received from your agency, then you will need to
log in to our secure website at https://web.pcgus.com/ncdma and click on the ‘View Received
Provider Documents’ link, which can be found under the ‘Provider’ tab.
6. Your site states that I am missing documentation, but I did send it.
If you have just uploaded your documentation and are referring to the grid results from the View
Received Provider Documents section of our website, please note that the grid on the website
will not update until we have processed your documentation.
If we have processed documents and it appears that we have incorrectly processed
documentation, please call the toll-free number provided on your letters and provide examples of
documentation which were sent, but which appear to be missing. We will perform a secondary
review to ensure that all documentation has been processed correctly.
7. The documentation you say is required is not required for the services which we provide.
For Behavioral Health cases, all providers must, at the least, provide:
- Authorization of Services - we are requesting the service authorization which
pertains to the recipient during the date(s) of service requested in the initial
medical records request
- Service Note (i.e. a document which details services rendered) - we are
requesting those service notes which pertain to the date(s) of service requested in
the initial medical records request and which document the interventions based on
the service(s) delivered. The note should contain the interventions, as well as the
documented amount of billed time
- Treatment Plan (which lists goals and the plan of action for a recipient’s
treatment) - we will only review a treatment plan which relates to the date(s) of
service requested in our initial medical records request. If your agency is not the
clinical home for a recipient and you do not have the recipient’s treatment plan
but your agency did provide services, then you will need to obtain a copy of that
treatment plan for the purposes of this review. If your agency is uploading
complete PCPs, then please also upload the recipient’s Introductory PCP.
- Admission Assessment (which documents recipient’s needs, as well as
suggested course of action/treatment) - we are requesting the assessment for the
service(s) being reviewed which documents the information required to show that
entrance criteria and criterion for medical necessity have been met
The above documents are required; however, we will accept all documentation
(i.e. case management notes, clinic visit notes, progress notes, psychiatric
evaluations, psychological and hospital evaluations and discharge summaries,
etc.) pertaining to the specified recipients on the specified date(s) of service which
may give additional support for services rendered.
Employee Documentation: We request all documentation from employee
personnel files as required in clinical policy 10A NCAC 27G.0202 (Personnel
- Start Date – this provides us with the basis of evaluating employees’
trainings (since trainings and other employee documentation must occur
within a certain timeframe from the employee’s date of hire). It is helpful
to include the start date on the first page of the employee’s file or to
provide a full listing of employees, including the date in which all
employees started with the agency
- Healthcare Registry Check – this documentation (which must be dated
before the recipients’ date(s) of service) provides information regarding
health care personnel who have pending investigations of allegations or
substantiated findings by the department of resident abuse, resident
neglect, misappropriation of resident or facility property, fraud against a
resident or facility, or diversion of drugs belonging to a resident or facility.
We require healthcare registry checks for all unlicensed staff.
- Criminal Disclosure – this documentation provides criminal background
information regarding health care personnel
* For Community Support providers (proc code: H0036), the only
document requirement is a criminal disclosure
* For other behavioral health services, we require the actual
background check or the SBI receipt
- Alternatives to Restrictive Intervention – NCI, CPI, or other Division
- Supervision Plan – we need evidence that paraprofessionals, associate
professionals, and qualified professionals (if applicable) are being
reviewed – we need the Supervision Plan pertaining to the date(s) of
service requested on the initial letter
- Crisis Response Training (if applicable)
- Person Centered Thinking (if applicable)
- Service Definition Training (if applicable)
- Intensive In-Home Training – (if applicable)
- PCP Instructional Elements – (if applicable)
We are also looking for documentation which demonstrates that employees “meet
minimum level of education, competency, work experience, skills and other
qualifications for the position” (again, from clinical policy 10A NCAC 27G.0202)
– this equates to resumes (for verification of experience) and diplomas (and
transcripts) as well
* For QPs, we will not accept a simple statement that a person is a QP – in order
to be considered a QP in our system, they must meet the minimum experience and
education requirements (as documented by resumes, transcripts, and diplomas).