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 Two Issues at the Long-Term Commitment Facilities, Department of Juvenile Justice: 1)Safety Threat to Employees & Juveniles; and 2)Event Reporting Process Integrity Allegations

The Legislative Oversight Committee of the South Carolina House of Representatives, referred allegations pertaining to the Department of Juvenile Justice (DJJ) which were generated during its ongoing oversight study of DJJ. Specifically, the safety issues focused on lack of control; lack of trust; and lack of adequate staffing. This review’s scope and objectives were: Investigate specific complainant allegations of DJJ employees underreporting, misreporting, or destroying ERs; Review the efficiency and effectiveness of DJJ’s event reporting process and follow-up on anomalies or potential patterns of systemic underreporting, misreporting, or missing ERs; and Assess juvenile and employee safety conditions through interviewing a cross-section of relevant employees, record review, and possibly an employee survey.