Partners is charged with ensuring that funds are being used for the appropriate level and intensity of services as well as in compliance with federal, state, and general accounting rules. The Partners’ Program Integrity Unit is responsible for billing audits for contracted providers. The Finance Department assists the Program Integrity Unit with the review of financial reports, financial statements, and accounting procedures. The Finance Department and Program Integrity Investigation Team work collaboratively with the provider in the collection of any determined paybacks.

Provider Self-Audit & Repayment

Inappropriate payments made by Partners to providers within its network inflates the costs of providing care to Medicaid and others receiving health care funded by tax dollars. Partners encourages providers to conduct self-auditing and reporting of identified overpayments. Partners retains its right and responsibility to identify and recover overpayments or take any other action available under law when it identifies overpayments.

Providers must submit written notification to the Partners’ Finance Department of any inappropriate payments identified and must clearly indicate the claim specific information and findings, preferably a copy of the specific claim detail with a minimum of the following data:

  1. Consumer Name (Last, First, Middle Initial)
  2. Medicaid ID Number
  3. Date of Service
  4. Procedure Code
  5. Individual Claim Number (ICN)
  6. Provider Number
  7. Amount Billed
  8. Amount Paid
  9. Paid Date
  10. Refund Amount
  11. Reason for Error

Partners’ reserves the right to apply penalties and interest to any overpayments made to Providers in which full repayment is not received within 30 calendar days.

Provider Self-Audit Protocol and Form

Chart of Findings and Plan of Correction Template

Reporting to State and Federal Authorities

Partners is obligated to report each case of potential health care fraud. Information reported to NC DMA must include, but is not limited to, the following:

  • Provider’s name and number
  • Source of the complaint
  • Type of provider
  • Nature of the complaint
  • Approximate range of dollars involved and the legal and administrative disposition of the case

Potentially fraudulent billing may include, but is not limited to:

  • Unbundling services
  • Billing for services by non-credentialed or non-licensed staff
  • Billing for a service the provider never rendered or for which documentation is absent or inadequate

Repayment Process and Paybacks

The Finance Department is responsible for the recovery of funds based on audit findings, including:

  • Failure to comply with state, federal, Medicaid or other revenue source requirements; or
  • Payment for a service or a portion of a service that should have not been allowed; or
  • Payment for a fraudulently billed claim.

It is the policy of Partners to recoup the amount owed from current and/or future claims. For paybacks that exceed outstanding claims, Partners invoices the provider the amount owed. The provider then has 30 calendar days from the date of the final determination of overpayment to pay the total amount owed. Balances that exceed 30 days from the date of final determination are subject to a 10% penalty, monthly accrued at an interest rate of 0.471% and possible collection fees and activities as permitted by law.