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Quality & Program Integrity
       
WV - DHHR      

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Introduction
Top Billing Errors
QPI FAQ
Contact: medsurs@wvdhhr.org

Introduction
The Office of Quality and Program Integrity (OQPI) is responsible for completing the activities required under 42 CFR Section 456. This mandate requires post payment review of paid claims to assure that services were provided by eligible providers, to eligible clients, that the services were medically necessary, appropriate to the patient’s medical condition and were provided in conformance with the service definitions set forth in the Medicaid Manuals. OQPI uses tools such as on-site reviews, desk reviews, and analysis of paid claims data to meet this mandate.

A recent contract with Health Watch Technologies (HWT) has expanded the capability of the OQPI  to complete this data analysis. The contract was awarded in September 2001. It is a multi-agency contract which includes Medicaid, Worker’s Compensation and PEIA. The services selected for review by HWT include: pharmacy, physician, transportation, ambulatory surgical, durable medical equipment, hospital, home health, laboratory, dental and services paid for by other state payors.

HWT analyzes the data and results are validated by the Bureau prior to dissemination. Reports are mailed to the provider in draft format with no request for repayment until the comment period has expired. Providers are given toll free access to discuss results and arrange for documentation review. Those providers with an identified repayment may select repayment terms that meet their business needs. Providers retain all administrative appeal rights.

The following information summarizes HWT activities to date.

 

Medicaid

 

Provider Type

 

Letters Sent

 

Number of Providers Receiving Letters

 

Overpayment Amount2

Pharmacy

2,016

561

$3,832,364

Physician

691

677

$744,426

Hospital1

214

93

$442,042

Laboratory

80

66

$98,446

Transportation

34

34

$88,488

Home Health Agencies

14

14

$76,164

Podiatrist

63

63

$54,543

Ambulatory Surgery

8

8

$13,899

Mental Health Rehab

2

2

$12,698

Chiropractor

6

6

$5,764

Independent Radiology

10

10

$4,426

Other

31

31

$14,658

TOTALS

3,169

1,565

$5,387,918

1Inpatient and Outpatient Hospital

2Based upon data from January 1999 forward

 

For the time periods analyzed, Medicaid overpayments were only .2% of total Medicaid expenditures of $3,503,142,915.  The following chart for Medicaid, shows the percentage of providers, by provider type, who received overpayment letters.  As is typical in our findings, it is usually only a small percent of providers who account for overpayments. 

 
Top Billing Errors
top of page Top Most Common/Costly Billing Errors

    In reviewing claims data, HWT identified the following as the most common and costly reasons for overpayments:

Office of  Quality and Program Integrity  / 350 Capitol Street Room 251 / Charleston, WV 25301-3709

Updated: 02/02/06