- 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 Consulting Group
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
DMA, 919-647-8000
- 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.
- 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 here:
- 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.
- 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 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 weresent, but which appear to be missing. We will perform a secondary review to ensure that all documentation has been processed correctly.
- The documentation you say is required is not required for the services which we provide.
For Personal Care Services:
Provider Documentation
- Division of Health Service Regulation (DHSR) Provider License
- Agency's Signed Medicaid Participation Agreement, Electronic Claims Submission Agreement and any change forms (such as change of address, change of ownership or agency name forms) that your agency has submitted to DMA
- Documentation of completion of PCS QA/UR activity - provider self-audit findings and plan to address findings
Recipient Information
- Physician Order (PO) –we are looking for the physician order which pertains to the date(s) of service requested in the initial letter
-PACT Form (PACT) – we are looking for the PACT form which pertains to the date(s) of service requested in the initial letter
- RN Supervisory Notes (RNN) – we are looking for the RNNs which pertain to the date(s) of service requested in the initial letter
- Aide Visit Logs (HA) – we are looking for the visit logs pertaining to the date(s) of service requested in the initial letter.
- RC (Recipient Consent for PCS) – there must be a recipient signature or the recipient’s mark. If there is no signature, then there needs to be documentation stating why the recipient is unable to sign.
- Providers may also submit documentation which they feel adds justification or descriptions of services (i.e. Narrative Notes) which may not be clear from the PACT form or the Visit Logs.
Employee Documentation – according to Clinical Policy 3C – we require copies of staff licenses, certifications and training/skills validation
- List of Office Staff (and titles) – including nursing staff and in-home aides
- List of Aide’s Assigned Clients and Visit Schedules
- Nurse Certification/Licensure – prior to 11/ 2009 RNs were also required to have PCS Certification
- In-Home Aide Credentials – also need verification of competencies by agency supervisory personnel of all skills required of home care services