NC Medicaid Behavioral Health and Intellectual/Developmental Disabilities Tailored Plans will launch July 1, 2024. Choice period ends on May 15, 2024. Please call to select your PCP. Find PCPs available in our health plan.
For help with non-emergency issues and questions, call Member and Recipient Services Monday through Saturday from 7 a.m. to 6 p.m. Please leave a message if you call us after these hours with a non-urgent request. We will call you back within 1 business day.
If you are in danger or need immediate medical attention, call 911. If you are thinking of hurting yourself or others, or are in emotional or mental pain or distress, call the Behavioral Health Crisis Line at 877-223-4617 at any time, 24 hours a day, 7 days a week. You can speak with someone who will listen and help.
Alliance Compliance Team Stands Strong against Fraud, Waste and Abuse
Alliance Health’s commitment to delivering high-quality services at a sustainable cost to the people we serve includes robust, proactive efforts to promote compliance and ethics among Alliance staff, providers and members.
“Compliance and ethics lay the groundwork for what we can and should do, how we should behave, and how we should interact with each other, the members we serve, and our providers,” said Matt Ruppel, Senior Director of Program Integrity.
Ruppel said one way to understand these concepts is that compliance will tell you what you can do, per laws and regulations, and ethics are what you should do. “One isn’t any more important than the other, they both hold the same value as far as I’m concerned,” he said.
A large part of our effort is a serious and proactive commitment to minimize the impact of fraud and abuse in the Medicaid system. “Every dime, every penny we lose to fraud, waste, and abuse is that much less money that is available to help our members get legitimate services,” Ruppel said.
In healthcare, fraud is when someone intentionally lies to an insurance company, Medicaid or Medicare to get money, waste is when health services are carelessly overused, and abuse happens when best medical practices aren’t followed, leading to expenses and treatments that aren’t needed.
Ruppel said healthcare anti-fraud groups report that about 10 percent of all money spent on healthcare is fraudulent, which can amount to billions of dollars across all commercial health plans, Medicaid and Medicare. “So anything we can do to prevent it is the most important thing,” he said.
“We spend a lot of our time recovering money, and investigating things that seem like they went wrong,” Ruppel said. “And the best thing we can do is prevent it from going out in the first place. Because once you pay that money out, it’s hard to get it back.”
To uncover fraud, waste and abuse, Ruppel’s team uses claims audits and data analytics to help identify aberrant billing that could signal wrongdoing, carelessness or lapses in oversight. They also rely on tips or alerts from Alliance staff or others involved in member care.
“The more that our employees can be educated about it, the more they can recognize an issue and say something if they see something,” he said. “And we want people to say something even if they’re not sure if it’s fraud. If you think it’s not right, report it, we’ll investigate it and figure it out.”
Ruppel’s team, the Special Investigations Unit, follows up on tips and alerts with diligent detective work, poring over records, reviewing provider monitoring data and interviewing staff, members and providers. When they determine that fraud has likely occurred, they refer the case to the NC Medicaid Office of Compliance and Program Integrity. If that office decides it’s a credible case, they send it to the Medicaid investigations division for criminal and civil investigation.
In some cases the unit’s investigations reveal that suspected fraud is actually the result of carelessness or shoddy practices by provider staff. “We often see bad controls and providers with an employee or maybe several employees that are cutting corners,” Ruppel said. The compliance team works with those providers to help them understand why they need to develop better controls and educate their staff.
Ruppel said that individuals can do their part to prevent healthcare fraud by safeguarding their health identity and their member number. “The best advice I can give is to treat it like a credit card, don’t just give it out,” He said.
He also advised to not sign documentation that is not complete or that you do not understand, and to always date anything you sign. “We will find treatment plan and signature pages where the guardian has signed it but there’s no date. So then that becomes the template that the provider will use whenever they need a signature page updated,” he said.
Alliance partners with WCPSS to boost youth engagement
In response to challenges in youth engagement and well-being created by the Covid-19 pandemic, Alliance Health, Wake County Public School System and Wake County Cooperative Extension are piloting a community-informed, data-driven strategy to help school staff and re-engage youth in...
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03/19/2024
Alliance Health Partners with NourishedRx to Support Members in TCL Program
Alliance Health announced today that it has entered into a strategic partnership with NourishedRx, a digital health and nutrition company based in Stamford, Connecticut, to support eligible members enrolled in North Carolina’s Transitions to Community Living (TCL) program. The new partnership will enable Alliance...
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1915C HCBS Innovations Waiver Renewal, July 1, 2024
The NC 1915(c) Home and Community Based Services Innovations Waiver’s current 5-year cycle period will expire on June 30, 2024. NC Medicaid’s goal is to renew the waiver with an effective date of July 1, 2024, for continuity of program planning....
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