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 Investigations, Audit, and Inspections divisions on dental, medical, nursing, and pharmacy services.
Medical Services is comprised of three units:
- Clinical Matter Subject Expert
- Acute Care Surveillance
- Quality Review
Clinical Subject Matter Expert
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 IG 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
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.
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.