Vaya Health is committed to monitoring provider performance, ensuring the integrity of our Medicaid managed care program and promoting the provision of high-quality services to our members. Vaya staff in the Network Performance and Integrity Department conduct multiple provider oversight functions, including:
- Responding to allegations of fraud, waste and abuse
- Referring suspected fraud to NC Medicaid for potential civil and/or criminal investigation by the Medicaid Investigations Division of the N.C. Department of Justice
- Auditing and investigating claims and service documentation
- Tracking, reviewing and reporting self-audits
- Conducting site and unlicensed alternative family living reviews
- Conducting complaint investigations, focused monitoring reviews and post-payment routine monitoring reviews
- Conducting health and safety investigations
- Referring complaints, grievances and investigations for licensed facilities to the N.C. Division of Health Service Regulation or the applicable oversight agency in other states
- Conducting three-way hospital quarterly reviews
- Monitoring providers’ contractual provisions, including scopes of work and performance-based indicators
- Tracking, gathering follow-up information and coordinating the review of incidents filed by providers in the state’s Incident Response Improvement System (IRIS)
- Conducting post-payment reviews of services that are not pre-authorized
- Providing technical assistance to providers