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Healthcare Audit Division

The Healthcare Audits Division (HAD) is responsible for conducting healthcare-related audits as requested by the Georgia Department of Community Health (DCH). The Division includes auditors in the Cost Report Audit Section, Claims Audit Section, and the CMO Access Monitoring Section.

All healthcare audits are performed on behalf of DCH. Services provided to DCH on a recurring basis include cost report audits, nurse aide testing and training audits,  nursing hour audits, and provider appeals. Additional types of audits are performed as requested by DCH.

 

Cost Report Section

 

Nursing home cost report audits are conducted to determine if the reimbursable costs claimed by the provider are reasonable and allowable. Reasonableness and allowability are determined based on federal and state laws, regulations, policies and procedures, as well as generally accepted accounting principles. Approximately 75 nursing home cost report field audits are conducted each year. In addition, approximately 340 nursing home cost report desk reviews are conducted each year.

DCH remits quarterly payments to nursing home providers to cover the cost of the nurse aide testing and training required by OBRA 87. Each nursing home receiving these payments is audited to determine if reported expenditures are accurate and allowable, to ensure the provider is not reimbursed more than the maximum allowed per aide trained, and to determine the amount of lump-sum settlement due to or from the provider. Approximately 50 nurse aide testing and training audits are conducted each year.

 A Medicaid provider may appeal the results of any state audit described above. The documentation provided with the appeal is analyzed and the provider’s appeal is evaluated to determine if the results of the audit should be modified. Approximately 50 provider appeals are evaluated each year.

 

Claims Audit Section

 

Financial and clinical auditors analyze claims paid by DCH to healthcare providers to determine whether individual claims are allowable and whether DCH has paid the provider the appropriate amount for services rendered. This includes not only analyzing raw data, but also reviewing medical records to determine if services were documented and medically necessary.

 

CMO Access Monitoring Section

 

Management analysts conduct quarterly access monitoring to help ensure Medicaid recipients have adequate access to care through the Medicaid program's Care Management Organizations (CMOs).