Overview
The Office of Quality Assurance (“QA”) is responsible for ensuring the fiscal and programmatic integrity of programs administered by the Department of Social Services (“Department”). In addition, QA is responsible for ensuring the integrity of administrative functions of the Department. QA has five separate divisions, each with unique program integrity functions: Audit, Investigations and Recoveries, Special Investigations, Quality Control and Third Party Liability.
The Audit Division
The Audit Division ensures compliance, efficiency, and accountability within federal and state programs administered by the Department by detecting and preventing mismanagement, waste and program abuse and ensuring that state and federal dollars are spent appropriately, responsibly, and in accordance with applicable laws and regulations. To achieve this objective, The Audit Division:
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Performs federally mandated audits of medical and health care providers that are paid through the various medical assistance programs administered by the Department;
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Reviews medical provider activities, audits claims, identifies overpayments, and educates providers on program integrity issues;
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Provides support and assistance to the Department Special Investigations Division in the ongoing effort to combat fraud and abuse;
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Performs audits of the Department’s operations, involving review of administrative and programmatic functions and the electronic data processing systems used in their support;
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Coordinates the Department’s responses to all outside audit organizations reviews performed on the Department, including but not limited to, the State Auditors of Public Accounts and federal audit organizations;
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Reviews federal and state single audit reports and performs audits of financial, administrative and programmatic functions of the Department’s grantees;
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Performs data analytics to identify aberrant billing activity and pursues collection of such overpayments; and
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Substantiates whether complaints received from various sources are valid and determines the proper disposition of the complaint including conducting an audit or forwarding to the Department’s Special Investigations Division.
Investigations and Recoveries Division
The Investigations and Recoveries Division is comprised of two units; the Client Investigations Unit and the Resources and Recoveries Unit. Both units have investigation staff located at both central and field office locations.
•Client Investigations Unit investigates alleged client fraud in various programs administered by the Department. This unit performs investigations via pre-eligibility, post-eligibility and other fraud investigation measures that include, but are not limited to, data integrity matches with other state and federal agencies. This unit also oversees the toll-free Fraud Hotline 1-800-842-2155 that is available to the public to report situations where it’s perceived that a public assistance recipient, a provider, or a medical provider may be defrauding the state.•Resources and Recoveries Unit is charged with ensuring that the Department is the payer of last resort for the cost of a client’s care by detecting, verifying, and utilizing third-party resources; establishing monetary recoveries realized from liens, mortgages, and property sales; and establishing recoveries for miscellaneous overpayments.
Special Investigations Division
The Special Investigations Division is comprised of two units; Provider Investigations and Provider Enrollment.
•Provider Investigations Unit is charged with the responsibility of coordinating and conducting activities to investigate allegations of fraud in the Connecticut Medical Assistance Program. When appropriate, credible allegations of fraud are referred to the Department’s law enforcement partners pursuant to a memorandum of understanding (MOU). Parties to the MOU are the Office of the Chief State’s Attorney, the Office of the Attorney General and the U.S. Department of Health and Human Services’ Office of the Inspector General. Each entity is responsible for independently investigating the Department’s referral to determine if a criminal and/or civil action is appropriate.•Provider Enrollment Unit is responsible for the review and approval of all provider enrollment and re-enrollment applications, on an on-going basis. This Unit also shares responsibility for ensuring federal and ACA requirements for provider enrollment are instituted and adhered to. Coordination of efforts between the Provider Investigations Unit and Provider Enrollment Unit strengthens Connecticut’s program integrity efforts.
Quality Control Division
Third Party Liability Division
The Third Party Liability Division is responsible for the Department’s compliance with federal Third Party Liability requirements and recovering tax-payer funded health care from commercial health insurance companies, Medicare and other legally liable third parties The Division manages programs that identify client third party coverage and recover client health care costs.