The Division of Medical Services conducts claims and medical record reviews on a variety of health and human services, including acute care utilization, hospital utilization, nursing facility utilization, research and detection, and pharmacy lock-in. The division also provides clinical consultation to the General Investigations, Audit, and Inspections divisions on dental, medical, nursing, and pharmacy services.

Medical Services is comprised of:

Clinical Subject Matter Expert team

The Clinical Subject Matter Expert (CSME) team includes a physician, dentist, dental hygienist, and pharmacist who provide clinical expertise to Inspector General investigations, audits, inspections, special collaborative initiatives, and OIG legal staff. The CSME team also communicates with Managed Care Organization (MCO) and Dental Management Organization (DMO) compliance departments to educate and to clarify questions regarding clinical documentation and medical/dental policy interpretation.

Acute Care Surveillance team

The Acute Care Surveillance (ACS) team identifies patterns of aberrant billing, performs Surveillance Utilization Reviews required by the federal Centers for Medicare and Medicaid Services, develops and runs targeted data queries to identify acute care billing outliers, and collects Medicaid overpayments.

Quality Review team

The Quality Review team conducts retrospective utilization review of hospitals and nursing facilities, and administers the pharmacy Lock-In Program. The Utilization Review team performs onsite and desk reviews of hospital claims and nursing facility Minimum Data Set forms for appropriate billing. Lock-In Program staff work with managed care organizations to monitor recipient use of prescription medications and acute care services.

Page links

Nursing Facility Utilization Review (NFUR) Stakeholder Information 

Hospital Stakeholder Information 

Document links

July 16 HUR stakeholder meeting agenda

OIG's Division of Medical Services recovered $11,442,224 in the third quarter of fiscal year 2018.