2019 Annual Fraud, Waste, and Abuse Training for Providers

Bradley Eckels, MA, LPCManager of Program Integrity

Overview of Presentation

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What do we do and why?

What we don’t do

Definitions and Types – Fraud, Waste, and Abuse

Background and Regulations for Program Integrity

Program Integrity Activities

Provider Responsibilities

Beacon- PA Documentation Requirements

Website/Resources

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What do we do and why?

Beacon Program Integrity Functions

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Each Behavioral Health Managed Care Organization (BH-MCO) or the primary contractor is required to have a Fraud, Waste, and Abuse (FWA) department.

The Beacon Program Integrity Department is responsible for all FWA investigations/audits of providers within our responsible counties.

We must report all audits to the Bureau of Program Integrity quarterly and we also make referrals for cases where Fraud, Waste or Abuse may have occurred.

We are Beacon’s liaison with local, state, and federal law enforcement.

We provide education, assistance, and training throughout the year.

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We are required to by law.

We believe in maintaining the integrity of the behavioral health services provided to Medicaid members.

We have a responsibility to educate providers on what is required.

The Medicaid population and behavioral health services are vulnerable to FWA.

To ensure that Medicaid behavioral health services are sustainable in the future.

Why do we do it?

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What we don’t do

What we don’t do

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Criminal investigations (Local, state, federal law enforcement)

Complaints or Grievances

Approve documentation templates

Investigate provider related HIPAA concerns

Licensing

Investigate quality of care concerns

Review medical necessity

NOTE: Some function’s listed above may be handled by other Beacon Departments.

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A Program Integrity audit ensures that the provider chart documentation matches the claim information

We also ensure that all regulatory requirements are met to bill for the service

If we determine that there is a quality issue an internal referral will be submitted

We collect overpayments based on violations of regulations, bulletins, the provider manual, etc.

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How is a Program Integrity Audit different

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Definitions and Types:Fraud, Waste, and Abuse

Program Integrity Definitions

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FRAUD

Any intentional deception or misrepresentation made by an entity or person in a capitated MCO, Primary Care Case Management, or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting.

Program Integrity Definitions

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WASTE

Thoughtless or careless expenditure, consumption, mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls

Program Integrity Definitions

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ABUSE

Any practices in a capitated MCO, Primary Care Case Management program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting

Other Program Integrity Definitions

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Compliance Program

Systematic procedures instituted to ensure that contractual and regulatory requirements are being met

Compliance Risk Assessment

Process of assessing a company’s risk related to its compliance with contractual and regulatory requirements

Compliance Work Plan

Prioritization of activities and resources based on the Compliance Risk Assessment findings

Types of Fraud, Waste, and Abuse

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Administrative/Financial

Falsifying credentials

Fraudulent enrollment practices

Fraudulent third-party liability reporting

Offering free services in exchange for a recipient's Medical Assistance identification number

Providing unnecessary services/overutilization

Kickbacks-accepting or making payments for referrals

Concealing ownership of related companies

Types of Fraud, Waste, and Abuse

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Abuse of Recipients

Physical, mental, emotional or sexual abuse

Discrimination

Neglect

Providing substandard or inappropriate care

Types of Fraud, Waste, and Abuse

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Denial of Medically Necessary Services

Denying access to services

Limiting access to services

Failure to refer to needed specialist

Types of Fraud, Waste, and Abuse

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Overutilization of Services

Providing unnecessary services

Unbundling multiple services

Overlapping services

Billing for excessive units

Documentation does not support the time billed

Types of Fraud, Waste, and Abuse

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Recipient

Forging or altering prescriptions or orders

Using multiple ID cards

Loaning his/her ID card

Reselling items received through the Medical Assistance program

Intentionally receiving excessive drugs, services or supplies

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Background and Requirements for Program Integrity

Federal Regulations

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Federal False Claims Act (FCA)

FCA is federal statute that covers fraud involving any federally funded contract or program, including the Medicare (as well as Medicare Advantage and Medicaid programs)

Any individual or organization that knowingly submits a claim he or she knows (or should know) is false and knowingly makes or uses, or causes to be made or used, a false record or statement to have a false claim paid or approved under any federally-funded health care program is subject to civil penalties

Potential penalties:

Triple damages and penalties between $5,500 and $11,000 for each false claim

Exclusion from participating in federally funded programs including Medicare and Medicaid

Criminal prosecution

Federal Regulations

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Balanced Budget Act (BBA)

Amended Social Security Act (SSA) to include healthcare crimes

Must exclude from Medicare and state healthcare programs for those individuals and entities convicted of healthcare offenses

Can impose civil monetary penalties for anyone who arranges or contracts with excluded parties

Federal Regulations

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Anti-Kickback Statute

A federal law (42 U.S.C. §§ 1320a-7b) that prohibits persons from directly or indirectly offering, providing or receiving kickbacks or bribes in exchange for goods or services covered by Medicare, Medicaid and other federally funded health care programs. These laws prohibit someone from knowingly or willfully offering, paying, seeking or receiving anything of value in return for referring an individual to a provider to receive services, or for recommending purchase of supplies or services that are reimbursable under a government health care program.

Violations of the law are punishable by the following:

• Criminal sanctions including imprisonment and civil monetary penalties

• The individual or entity may also be excluded from participating with other federally funded programs, including Medicare and Medicaid

Federal Regulations

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Fraud Enforcement and Recovery Act of 2009 (FERA)

A federal law that increased detection and law enforcement of crimes related to fraud

FERA amended the FCA definition of fraud

FERA infused millions of dollars into law enforcement initiatives to combat fraud in the Medicare and Medicaid programs

FERA included whistle-blower protections

Federal Regulations

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Patient Protection and Affordable Care Act (PPACA –Healthcare Reform Act)

A federal law for increased access to healthcare that included provisions specific to fraud and abuse. PPACA increased penalties and enforcement of healthcare crimes

PPACA mandates state and federal agencies to communicate about provider enrollment for federally-funded programs

PPACA required Medicare and Medicaid providers to have a compliance program

PPACA reduced the requirements of “intent”

PPACA stated that overpayments must be reported and returned within 60 days

Federal Audits and Inspections

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Medicaid Integrity Program (MIP)

Medicaid Integrity Group (MIG)

Medicaid Integrity Contractors (MIC)

Medicare Zone Integrity Contractors (ZPIC)

Medicare Recovery Audit Contractors (RAC)

http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol4/xml/CFR-2011-title42-vol4-sec455-23.xml

Federal Audits and Inspections

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Pennsylvania Collaboration

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“All together, as providers, BH-MCOs, OMHSAS, and BPI, we can help to reduce FWA to decrease wasteful spending in our system.”

Other Enforcement Entities

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U.S. Department of Health and Human Services, Office of Inspector General (OIG)

U.S. Department of Justice (DOJ)

Office of the State Attorney General (AG) – Medicaid Fraud Control Unit (MFCU)

Federal Bureau of Investigation (FBI)

Department of Insurance (DOI)

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Program Integrity Activities

Beacon-PA Program Integrity Audits

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Routine Audits

• Scheduled or standard data validation audits and claims sampling of contracted providers to ensure compliance with documentation, laws, regulations and billing requirements. The purpose of these audits will also be to monitor providers for possible fraud and abuse. Control assessments, compliance programs, and policies and procedures will be monitored and analyzed for inconsistencies, risk, etc.

• Audit procedures will be followed for routine audits

• https://s18637.pcdn.co/wp-content/uploads/sites/9/Audit-Process.pdf

Beacon-PA Program Integrity Audits

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Audit Procedures

• Audit notification

• Pre-audit conference call with provider

• Entrance meeting with provider for on-site reviews (1st day of audit)

• Preliminary exit meeting with provider for on-site reviews (last day of audit)

• Exit conference call with provider

• Report to provider

• Provider audit response (CAP or reconsideration)

Beacon -PA Program Integrity Audits

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Investigations or allegations of potential fraud and abuse that may involve other oversight entities are NOT routine audits and can deviate from the audit procedures

FWA Trends in Behavioral Health that Result in Audits

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Billing for services not rendered

Overlapping services

Providers engaging in dual relationships with members

Documentation that doesn’t meet the standards in PA Code, MA Bulletins, Beacon Program Integrity website, etc.

• Tx plans not being signed or update appropriately

• No encounter forms

Forgery of recipient signatures or asking members to sign blank forms

Billing for non-billable services

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Corrective Action Plans (CAP) are requested when an audit does not meet the threshold set by the program integrity department (10% error rate) or when deemed appropriate by the auditor.

The Beacon-PA Program Integrity department accepts and asks providers to adhere to the PA Bureau of Program Integrity CAP guidelines

http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/capguidelines/index.htm

Corrective Action Plans

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1. Determine who has the knowledge and authority to make the decisions, to develop the plan, to require the changes, and to coordinate across functional areas of responsibility.

2. Assign individual responsibility and an overall CAP coordinator role.

3. Focus on error concentrations that have the most significant impact on the error rate.

4. Identify the root cause of the error: when did it occur, and who or what caused it?

5. Identify operational policies and procedures that caused the error.

6. Develop a correction strategy that wholly addresses each deficiency

CAP Guidelines

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7. Identify major tasks required to implement the corrective action, sequential timelines addressing the most critical areas first, target implementation dates, and key personnel/components responsible for each action.

8. Address practice/process, structure, training, communication needs, monitoring and follow-up activities.

9. Assess proposed CAP for potential unintended consequences of system changes on other areas of the business; adjust as needed.

10. Assess whether the corrective actions in place are effective at reducing or eliminating error causes.

CAP Guidelines (Continued)

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Billing for travel or transportation

Administrative processes (copying, typing, etc.)

Services performed while engaged in a dual relationship with the member/family

Services performed outside the scope of treatment plan, service description, or professional license

Supervision

Recreation

Cancelled appointments

Non-billable services

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Provider Responsibilities with Compliance

Compliance Program

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Compliance Plan

1. Written policies and procedures

2. Compliance Officer and Compliance Committee

3. Effective training and education

4. Effective lines of communication between the Compliance Officer, Board, Executive Management and staff (incl. an anonymous reporting function)

5. Internal monitoring and auditing

6. Disciplinary enforcement

7. Mechanisms for responding to detected problems

8. Compliance Programs must be effective

Pennsylvania Regulations - Provider Responsibilities

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Self-Audit and Disclosure Protocol• DHS outlined specific procedures to follow on the following

webpage:

http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/medicalassistanceproviderselfauditprotocol/

• DHS requires providers to return overpayments within 60 days of identifying overpayments

• For PA HC PSR, providers should conduct self-audits and return overpayments to BH-MCO (Beacon-PA)

http://www.vbh-pa.com/fraud-waste-and-abuse/#reporting

• Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered

Pennsylvania Regulations - Provider Responsibilities

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Medically Necessary Services• § 1101.21a. Clarification regarding the definition of ‘‘medically

necessary’’—statement of policy.

A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that:

(1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability.

(2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability.

(3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

Pennsylvania Regulations - Provider Responsibilities

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Minimum Documentation Requirements

• Chapter 1101.51 (e), states that:

Providers shall keep records that “fully disclose the nature and extent of the services rendered to MA recipients, and that meet the criteria established in this section and additional requirements established in the provider regulations.”

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Beacon- PA Documentation Requirements

Documentation

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Documentation – Just as Important as the Service:

• The ability of the physician and other healthcare professionals to evaluate and plan the patient’s immediate treatment and to monitor his/her healthcare over time

• Communication and continuity of care among the physicians and other healthcare professionals involved in the patient care

• Accurate and timely claims review and payment

• Appropriate utilization review and quality of care evaluations

• Collection of data that may be used for research and education

• Evidence that the services were provided

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Consent To Treatment

Consent to Treatment vs. Releases

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1. Both give permission

2. Consent to Treatment is also known as informed consent. This document describes the services that are going to be performed and also educates members about any risks that may result

3. Release of Information (ROI) is a document that gives one provider or entity the ability to share a member’s information with another provider or entity

PA Regulations for Consent Forms

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Pennsylvania Code

• Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html

§ 1101.75. Provider prohibited acts.a)An enrolled provider may not, either directly or

indirectly, do any of the following acts: 10) Except in emergency situations, dispense, render or provide a service or item without a practitioner’s written order and the consent of the recipient or submit a claim for a service or item which was dispensed or provided without the consent of the recipient.

PA Regulations for Consent Forms

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Pennsylvania Code

• Chapter 5200 Psychiatric Outpatient Clinics

http://www.pacode.com/secure/data/055/chapter5200/chap5200toc.html

§ 5200.41. Records.a)Under section 602 of the Mental Health and Mental

Retardation Act of 1966 (50 P. S. § 4602), and in accordance with recognized and acceptable principles of patient record keeping, the facility shall maintain a record for each person admitted to a psychiatric clinic. The record shall include the following:

4) Appropriately signed consent forms.

Beacon-PA Requirements for Consent Forms

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Beacon-PA Provider Manual

• Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

– 8) Each record includes the patient’s address, employer or school, home and work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms and guardianship information, if relevant;

– 26) Informed consent for medication and the patient’s understanding of the treatment plan are documented;

Minimum Documentation for Consent Forms

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Minimum Documentation Standards:• Name and signature of the member, or if appropriate, legal representative

• Name of the provider (should correspond with license)

• Type of services and/or treatment

• Benefits and any potential risks

• Alternative services and/or treatment

• Date and time consent is obtained

• Statement that treatment and services were explained to patient or guardian

• Signature of person witnessing the consent (clinician)

• Name and signature of person who explained the procedure to the patient or guardian

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Release of Information

Beacon-PA Requirements for Release of Information

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Beacon-PA Provider Manual

• Treatment Record Reviews

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_reviews.htm

Beacon-PA will gain access to treatment records by reviewing them at the provider’s office or by asking the provider to photocopy and send the records. Prior to treating a member, the provider should obtain the member’s written consent to share their treatment information and records with VBH-PA.

Minimum Documentation for Release of Information

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Minimum Documentation Requirements

• Member’s name or Medical Assistance identification number

• Date of release

• Expiration of release

• Dates of service range for the release

• Statement that the complete member record including treatment information in progress notes and evaluations will be released for audit, quality, and payment purposes

• Signature of Member or Guardian and signature date

• Clinician’s signature, credentials, and signature date

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Treatment Plan

Treatment (Service) Plans

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Main Purpose of Treatment (Service) Plans

1. Definition of Treatment

Goals and Objectives

Utilization

2. Description of Informed Consent

As recorded on the Consent Form

3. Mechanism to Track Individual Plans, Treatments, and Outcomes throughout Treatment

PA Regulations for Treatment Plans

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Pennsylvania Code

• Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html

1101.51. Ongoing responsibilities of providers.(1) General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

(v) Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.

Beacon-PA Requirements for Treatment Plans

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Beacon-PA Provider Manual

• Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

3. Accurately document at least the following on each case for which services are being provided:

a.Member information (demographic);b.Clinical information;c.Clinical assessments;d.Treatment plans;e.Services provided;f. Contacts with member’s family, guardians or significant

others;g.Treatment outcomes; andh.PCPC/ASAM for substance abusers;

Beacon-PA Requirements for Treatment Plans

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Beacon-PA Provider Manual

• Treatment Records

5. All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.

6. It is necessary that the provider initiating treatment document an initial treatment plan that describes the active target interventions with specific, measurable goals, and stated in behavioral terms, at the level of care proposed;

Beacon-PA Requirements for Treatment Plans

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Beacon-PA Provider Manual

• Treatment Records

24. Treatment plans are consistent with diagnoses and have objective, measurable goals and estimated time lines for achieving goals or resolving problems;

25. The focus of treatment interventions is consistent with the treatment plan goals and objectives;

26. Informed consent for medication and the patient’s understanding of the treatment plan are documented;

27. Progress notes describe the patient’s strengths and limitations in achieving treatment plan goals and objectives;

Beacon-PA Requirements for Treatment Plans

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Minimum Documentation Requirements

1. Must be completed according to service requirements

2. Treatment plan date

3. Diagnoses and/or symptoms addressed

4. Clinician’s signature, credentials, and signature date

5. Member or guardian’s signature and signature date

6. Evidence member or guardian participated with treatment plan development

7. Goals and objectives based on evaluation and mental health strengths and needs

Beacon-PA Requirements for Treatment Plans

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Minimum Documentation Requirements

8. Treatment objectives and prescribe as an integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives

9. Treatment goals are measurable

10. Treatment goals have established timeframes

11. Treatment plan address notes less restrictive alternatives that were considered

12. Treatment plan is easy to read and understand

13. Treatment plan documents necessity for services

14. Treatment plan documents the utilization of services

Treatment Plans Findings

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Common Findings No valid treatment plan for date of service

Incomplete treatment plan for date of service– Missing member/parent signatures– Does not include frequency of services, such length of

service and session per week or month– Does not include diagnosis and/or symptoms and

behaviors– Does not describe consent to treatment and/or

member/parent involvement – Treatment goals and objectives are not measurable – Treatment goals and objectives do have timeframes– Treatment plan does not reference information from

evaluation

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Progress Note

Progress Notes

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Main Purpose of Progress Notes

1. Document progress at each visit, change in diagnosis, change in treatment and response to treatment

2. Document medical necessity and justification for payment from Medical Assistance

PA Regulations for Progress Notes

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Pennsylvania Code

• Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html

§1101.51. Ongoing responsibilities of providers.1. General standards for medical records. A provider, with the

exception of pharmacies, laboratories, ambulance services and suppliers of medical goods and equipment shall keep patient records that meet all of the following standards:

i. The record shall be legible throughout. ii. The record shall identify the patient on each page.iii. Entries shall be signed and dated by the responsible

licensed provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed and dated.

PA Regulations for Progress Notes

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Pennsylvania Code

• Chapter 1101 General Provisionsiv. The record shall contain a preliminary working

diagnosis as well as a final diagnosis and the elements of a history and physical examination upon which the diagnosis is based.

v. Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities and dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.

vi. The record shall indicate the progress at each visit, change in diagnosis, change in treatment and response to treatment.

vii. The record shall contain summaries of hospitalizations and reports of operative procedures and excised tissues.

PA Regulations for Progress Notes

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Pennsylvania Code

• Chapter 1101 General Provisionsviii.The record shall contain the results, including

interpretations of diagnostic tests and reports of consultations.

ix. The disposition of the case shall be entered in the record.

x. The record shall contain documentation of the medical necessity of a rendered, ordered or prescribed service.

Beacon-PA Requirements for Progress Notes

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Beacon-PA Provider Manual

• Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

5) All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment and disposition/discharge plan. Medical and psychological treatment documentation and progress notes must be current and treatment plans shall be updated as necessary for the level of care.

Minimum Documentation for Progress Notes

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Minimum Documentation Standards

1. Must be completed for each billable encounter

2. Name or Medical Assistance identification number

3. Date of service

4. Start and stop times of service

5. Units match the claims billing

6. Place of service (specific location for community services)

Minimum Documentation for Progress Notes

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Minimum Documentation Standards

7. Reason for the session or encounter

8. Treatment goals addressed

9. Current symptoms and behaviors

10. Interventions and response to treatment

11. Next steps and progress in treatment

12. Narrative with the clinical justification to support utilization and time billed

13. Supporting documentation, when applicable

14. Clinician’s signature, credentials, and signature date

Progress Notes Findings

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Common Audit Findings:

No progress note

Progress note does not provide specific location

Progress note does not have start and stop times

Progress note is not signed/dated by the clinician

Supporting documentation is not attached (BHRS-programming)

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Encounter Form

Encounter Forms

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Encounter Form

1. Verify services were provided

Encounter form must be signed after the session

2. Meet the Federal regulations for Medicaid programs

42 CFR – Public Health – 455.20 Recipient verification procedure

a) The agency must have a method for verifying with recipients whether services billed by providers were received

PA Regulations for Encounter Forms

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Pennsylvania Bulletins

• PA Medical Assistance Bulletin #99-89-05

The Department’s policy has always been that medical assistance invoices must have either the recipient’s signature or the words “signature exception” appearing in the signature field. The signature certifies that the recipient received a medical service or item that the recipient listed on the Medical Service Eligibility Card is the individual who received the service.

PA Regulations for Encounter Forms

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Pennsylvania Bulletins

• PA Medicaid Bulletin# 99-03-021, Health Insurance Portability and Accountability Act (HIPAA) Transaction and Code Sets Updates, December 2003

Providers who bill via continuous-print claim forms (pin fed) or electronic media must retain the recipient’s signature on file using the Encounter Form. The purpose of the recipient’s signature is to certify that the recipient received the service from the provider indicated on the claim form, and that the recipient listed on the Pennsylvania ACCESS Card is the individual who received the service.

Beacon-PA Requirements for Encounter Forms

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Minimum Documentation Standards

1. Must be completed for each billable encounter (except for services that are excluded from encounter form requirements)

2. Member name including member identification number (as required in the PA Medicaid Bulletin)

3. Type of service

4. Date with start and stop times

5. Total units billed

6. Signature of Member for each encounter

7. Clinician’s signature, credentials, and signature date

Encounter Form Findings

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Common Audit Findings:

• No encounter form

• No encounter form entry for signature exempt services

• Encounter form is not signed by member, parent, guardian, or agent

• Encounter form does not include start and stop times

• Encounter form does not include type of service

• Encounter form not signed by clinician

• Correction to encounter form is not initialed and/or dated

• Encounter form details (service code, units, time) do not match progress note or claim

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Website/Resources

Beacon-PA Provider Links

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• Signing up for ValueAdded newsletter

• Provider Manual

• Forms

• Training

• Services Webpage

Beacon-PA Fraud and Abuse Links

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Compliance Policies and Processes

• Minimum Documentation Standards

Reporting Procedures

• Self-reports

• Referrals

Laws and Regulations

Training

Program Integrity Links

Questions?

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Bradley Eckels, MA, LPCManager of Program Integrity

Beacon Health Options724-744-6520

Bradley.Eckels@BeaconHealthOptions.com

http://www.vbh-pa.com/fraud_abuse.htm

Pennsylvania Regulations - Provider Responsibilities

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Provider Responsibilities 1101

• http://www.pacode.com/secure/data/055/chapter1101/s1101.51.html

Medically Necessary Services 1101

• http://www.pacode.com/secure/data/055/chapter1101/s1101.21a.html

Provider Prohibited Acts 1101

• http://www.pacode.com/secure/data/055/chapter1101/s1101.75.html

State Regulations

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Pennsylvania Code

Chapter 55 Part III. Medical Assistance Manual

http://www.pacode.com/secure/data/055/partIIItoc.html

General Regulations

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html

Payment Regulations

http://www.pacode.com/secure/data/055/chapter1150/chap1150toc.html

Medical Assistance Bulletins

http://www.dhs.pa.gov/publications/bulletinsearch/index.htm

State Regulations

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Pennsylvania - PA PROMISe

PA PROMISe Provider Handbooks

www.dhs.pa.gov

PA Recovery (for information by level of care)

http://www.parecovery.org/

Pennsylvania HealthChoices

• HealthChoices Behavioral Health Publications

http://www.dhs.state.pa.us/cs/groups/webcontent/documents/manual/p_003130.pdf

Beacon-PA Provider Manual Requirements

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Beacon- PA Provider Manual

• http://www.vbh-pa.com/provider/info/prvmanual/toc.htm

Beacon- PA FWA Webpage

• http://www.vbh-pa.com/provider/info/prvmanual/6_ClmsPyt/fraud_abuse.htm

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Thank you