The Program Integrity Provider Reviews addresses potential and actual fraud and abuse of DHMH programs by external providers and recipients. Program Integrity works with DHMH programs to recover funds inappropriately paid. Program Integrity seeks to prevent future fraud by encouraging and providing training for providers.
Investigations and Clinical Support supports both Divisions of Program Integrity and the Surveillance Utilization Review Subsystem by assisting the auditors in conducting claims reviews of Medicaid providers and investigating non-conforming billing patterns detected by SURS.
Surveillance Utilization Review Subsystem (SURS) is a sub-system of the Medicaid Management Information System, which maintains and stores Medicaid claims data. SURS detects potential misuse of Medicaid by program recipients and providers through data analysis; provides information to facilitate investigation of fraud, waste, and abuse; and produces comprehensive reports for the utilization review staff designed to assist in analyzing quality of care and developing program policy.
Medicaid Recipient Fraud Investigations responses to referral submitted by Local Health Departments, Local Department of Social Services and community at large, and investigates allegations of suspected fraud and abuse by Medicaid recipients of the Maryland Medical Assistance Program.
Medicaid Special Projects conducts reviews on the request of the DHMH Office of the Secretary and by mandate from the federal government. This unit reviews, monitors, and analyzes recipient eligibility determinations to ensure that eligibility determinations are accurate and in compliance with all Federal and State regulations and policies.
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DHMH Internal Audits performs periodic examinations and follow-up reviews of the accounts, records, procedures, and policies of DHMH administrations, and facilities, (not including the Medicaid Program which has its own dedicated Internal Audit Division), to help safeguard the Department’s assets by minimizing various internal control risks. Also, performs external audits and coordinates responses to external audit reports. The Division helps to prepare DHMH units for legislative and federal audits by ensuring that DHMH administrations have implemented corrective actions sufficient to resolve previously cited audit findings, and reviews problem areas to prevent future audit deficiencies. For more information
Medicaid Internal Audits performs periodic examinations and follow-up reviews of the accounts, records, procedures, and policies of the State’s Medicaid Program DHMH administrations, and facilities, to help safeguard the Department’s assets by minimizing various internal control risks. Also, performs external audits and coordinates responses to external audit reports. The Division helps to prepare DHMH units for legislative and federal audits by ensuring that DHMH administrations have implemented corrective actions sufficient to resolve previously cited audit findings, and reviews problem areas to prevent future audit deficiencies. For more information
DHMH External Audits conducts audits of human services vendors receiving funding from the Department to ensure State funds are expended and reported in accordance with contract provisions, laws, regulations, and generally accepted accounting principles. The audits determine over or underpayments. For more information
The Corporate Compliance and Privacy Office assures the Department complies with the Code of Conduct, Corporate Compliance policies, privacy policies and the Health Insurance Portability and Accountability Act (HIPAA). The Division provides Corporate Compliance and HIPAA privacy training and investigates suspected misconduct, fraud, waste, and privacy violations by DHMH employees. In addition, this division seeks to ensure that DHMH employees comply with ethical standards of conduct. The Division serves as a liaison to the State Ethics Commission in filing Financial Disclosure Statements and addresses conflicts of interest.
The Institutional Review Board (“IRB or “Board”) is the unit within the Department of Health and Mental Hygiene (“DHMH” or “Department”) responsible for reviewing research to ensure that the rights, safety, and dignity of human subjects are protected. The IRB was established by the Department in 1977 in response to federal regulations requiring that an organization conducting human subject research with Public Health Services funding have that research reviewed and approved by an IRB. For more information
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