Bureau of Program Integrity (BPI)

The Bureau of Program Integrity (BPI) ensures Medicaid recipients receive quality medical services and that Medicaid 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 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 includes medical professionals responsible for preventing, detecting, deterring, and correcting fraud, abuse, and wasteful practices by providers of MA services, including managed care organizations, applying administrative sanctions, and referring cases of potential fraud to the appropriate enforcement agency. This responsibility includes evaluating services rendered by medical providers and managed care organization 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.

Divisions & Responsibilities

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 managed care organizations under contract to DHS.

The Data Investigation and Analysis 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.

The Inpatient/Outpatient Behavioral Health Review Section is responsible for the review and oversight of all mental health, mental retardation and drug and alcohol providers within the state. Residential Treatment Facilities are reviewed on-site under Federal guidelines. This unit coordinates with OMHSAS and OCYF to provide education regarding the quality of care, safety and medical necessity. Referrals are researched and reviewed for possible fraud and abuse.

The Pharmacy Review Section ensures enrolled Medical Assistance (MA) Pharmacy providers render quality services in accordance with State and Federal rules and regulations; applies administrative sanctions and refers cases of potential fraud to the appropriate enforcement agency. This section is also responsible for the preclusion of MA providers, individuals and entitles who are then excluded from rendering, ordering or arranging for services for MA recipients.

The Managed Care Unit coordinates referrals from managed care organizations, reviews fraud and abuse programs of managed care organizations under contract to DHS, and participates on core teams that monitor the managed care organizations.

This division also administers the MA Provider Compliance Hotline, coordinates and manages provider complaints, and initiates mandated preclusion actions.

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 Hospital-Based Services Section is responsible for the review of hospice providers, 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 Home and Community Based Services Section reviews Home Health, Durable Medical Equipment, Laboratory and Physical/Occupational Therapy 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, medically necessary and quality care was provided.

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)

Administrative Section

Administrative Unit: The Administrative Unit provides all administrative support to TPL.

Recovery Section

• Referral and TCT Units: The Referral and TCT 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.
• Financial Accountability Unit: This unit has the responsibility to provide statements of claim for all personal injury and estate recovery claim requests. The Unit processes, tracks and reports on all financial transactions performed within the Division of Third Party Liability. HIPP Program and Medical Assistance for Workers with Disabilities (MAWD) program payments are received, recorded and deposited by the Unit.
• Support Unit: The Support 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

• Contract Management Unit: The Unit is responsible for monitoring all TPL/coordination of benefits (COB) activities (i.e., resource referrals, processing of claims, etc.) of the Physical Health and Behavioral Health MCOs that participate in DHS' HealthChoices Program. This unit also provides support to other areas within TPL and DHS (Office of Mental Health and Substance Abuse Services, Bureau of Managed Care Operations, etc.) when issues involving managed care arise.
• 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 handles development and testing of the MAWD automated system for collection of MA premiums. The Unit is also responsible for establishing/monitoring all data exchange contracts with 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 CAOs, 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. This unit also monitors two contractors that do supplemental work for TPL.

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 TPL was given the responsibility to implement this initiative, which we called the Health Insurance Premium Payment (HIPP) Program.

In July 2001, the HIPP Program was tasked with helping to administer MAWD and the Breast and Cervical Cancer Prevention and Treatment (BCCPT) initiatives due to our expertise in employer contact and interpretation of insurance policies.

Act 77 of 2001 established legislation to implement MAWD. MAWD enables an individual with disabilities and earnings from employment to receive Medicaid benefits due to the program's higher income and resource limits, and ensures the availability of health care benefits when an individual with disabilities enters the workforce. The HIPP Program developed and implemented an application to track and report premium payments for individuals determined eligible by the County Assistance Office (CAO) for the MAWD program.

The BCCPT Act of 2000 amended Title XIX of the Social Security Act by giving states the option of providing full Medicaid benefits to uninsured and under-insured women under the age of 65, screened and diagnosed with either breast or cervical cancer. The HIPP Program provides technical support to the CAO by reviewing the applicant's existing insurance policy and determining "creditable coverage" as defined by the Health Insurance Portability and Accountability Act (HIPAA).

Pennsylvania's HIPP Program consists of five regional offices, covering areas similar to the Office of Income Maintenance's, CAO regions. Although the HIPP Program receives referrals from many agencies and departments, the primary source of referrals is from the CAOs. When the availability of employment-related group health insurance is identified during the intake or redetermination process, the information is added to the employer screen on the Client Information System (CIS).

• HIPP Policy Unit: The HIPP Policy Unit reviews and analyzes federal and state legislation and regulations to determine the impact on the HIPP Program, and prepares draft legislation to strengthen current law impacting HIPP activities. The Unit is also responsible for the HIPP automated system, including development and testing. Other HIPP Policy Unit responsibilities include writing program policies and procedures, outreach, and training.
• HIPP Operations Unit: The HIPP Operations Unit consists of five regional offices; Chestnut Ridge, Clarks Summit, Harrisburg, Torrance and Warren. This unit's responsibility is to determine cost effectiveness and enroll cost-effective applicants into the HIPP Program.
• The HIPP Operations Unit determines cost effectiveness of employer group health plans (EGHP) and enrolls eligible MA recipients into cost-effective employer group health insurance. The enrolled HIPP cases are maintained by performing scheduled cost- effective re-evaluations; responds to information obtained from change report forms and phone calls; and resolves HIPP status code reports. It contacts employers of recipients enrolled in the DHS' MAWD program and arranges for MAWD payments to be sent to the DHS. The Unit also processes Breast and Cervical Cancer Prevention and Treatment (BCCPT) referrals from the CAOs to determine credible coverage as defined by the HIPAA regulations.

* Please Note: All phone numbers use the 717 area code