Health Reform: Fraud and Abuse Workgroup

The Health Reform Fraud and Abuse Workgroup examined new program integrity provisions under Medicaid and Medicare, identifying ways to meet new federal requirements, and developing strategies to educate providers about new financial integrity and fraud and abuse reporting requirements.

Report | Executive Summary | Presentation: Impact of Affordable Care Act on North Carolina
Al Koehler
Deputy Commissioner/Director, Criminal Investigations Division
North Carolina Department of Insurance
Tara Larson, MAEd
Chief Clinical Operations Officer, Division of Medical Assistance
North Carolina Department of Health and Human Services
Project Director  Sharon Schiro
Project Director
North Carolina Institute of Medicine
Workgroup Overview

The Affordable Care Act (ACA) includes provisions aimed at reducing fraud and abuse. For example, providers that have been excluded from participation in one federal program will now be excluded from participation in other federal health programs. The ACA includes expanded data reporting and matching activities to identify fraud and abuse, and increased penalties and federal powers to investigate fraud and abuse. The Fraud and Abuse Workgroup will examine these provisions, and try to educate providers to ensure they understand the new requirements of the Act.

As part of this effort, the Fraud and Abuse Workgroup will work to:

  • Examine new program integrity provisions under Medicaid, Medicare (as it affects the state), and insurance

  • Identify implementation steps to meet new federal requirements

  • Understand and educate providers on financial integrity and fraud and abuse reporting requirements

Information about the Affordable Care Act

General information about health reform including presentations, a summary of funding opportunities, and helpful links is available here.

Workgroup Background

The overall goal of this effort is to identify the decisions the state must make in implementing health reform. The Advisory Group and workgroups also plan on identifying potential funding opportunities to ensure that we are aware of, and take advantage of, any potential funding opportunity that will help us improve population health, access to care, and health care quality. We want to build on North Carolina's existing strengths and ensure that the decisions made in implementing the federal legislation serve the best interests of the state as a whole.

The effort will be led by Lanier Cansler, Secretary of the NC Department of Health and Human Services, and Wayne Goodwin, Commissioner of the NC Department of Insurance. The new federal health reform legislation will have significant impact on the way that health care is delivered in North Carolina.

To help the state prepare for these changes, eight different workgroups are being established:PreventionSafety NetHealth Professional Workforce, Health Insurance Exchange and Insurance OversightMedicaidNew Models of CareQualityFraud and Abuse.

This planning effort will be led by an Overall Advisory Group that will help coordinate the work of each of these workgroups. Each workgroup will meet approximately one time per month from August 2010-August 2011 to review specific sections of the legislation and examine any new funding opportunities that are made available as part of this legislation.