Review of Program Integrity Operations At Six Managed Care Organizations Delivering Medicaid Services under a Contract with the South Carolina Department of Health & Human Services

The State contracted with six managed care organizations to deliver Medicaid managed care at an annual cost of $2.7 billion, representing 10% of the State’s annual budget, to 750,000 Medicaid beneficiaries in South Carolina. This review’s scope and objectives were: Test the six MCOs’ compliance and effective execution of the SCDHHS’s managed care contract “Section 11 - Program Integrity” focusing on the operational components of pre-payment review and post-payment review. Identify opportunities to improve SCDHHS’s biennial managed care contract, contract monitoring, and MCO compliance and effective execution of the contract.

Review of Managing the Fraud Risk in the Disaster Supplemental Nutrition Assistance Program (D-SNAP), Administered by the Department of Social Services

This review was initiated based upon allegations from multiple sources of possible fraud in the Disaster Supplemental Nutrition Assistance Program (D-SNAP) administered by the South Carolina Department of Social Services (SCDSS), which was implemented in response to the 10/3/2015 statewide flooding from Hurricane Joaquin. This review’s scope and objectives were: Assess SCDSS’s D-SNAP implementation for compliance with federal guidelines, with emphasis on fraud preventative controls; Assess the SCDSS’s post-disaster review and audit methodology for compliance with federal guidelines, with emphasis on understanding the fraud risks and resolution strategies; and Identify residual risk/suspected fraud not addressed through the SCDSS review and available opportunities to address.