ASSURING MEDICAID ASSURING MEDICAID DENTAL COMPLIANCEDENTAL COMPLIANCE

06/29/201106/29/2011JAMES G. SHEEHANJAMES G. SHEEHAN

NEW YORK MEDICAID INSPECTOR GENERALNEW YORK MEDICAID INSPECTOR GENERALJames.Sheehan@OMIG.NY.GOVJames.Sheehan@OMIG.NY.GOV

518-473-3782 518-473-3782 Nancy.delPrado@OMIG.NY.GOVNancy.delPrado@OMIG.NY.GOV

518-408-0610518-408-0610Patricia.Branson@OMIG.NY.GOVPatricia.Branson@OMIG.NY.GOV

518-473-1915518-473-1915

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PURPOSE OF OMIG WEBINARS-PURPOSE OF OMIG WEBINARS-FULFILLING OMIG’S DUTY IN FULFILLING OMIG’S DUTY IN NYS PHL SECTION 32 -NYS PHL SECTION 32 -•§ 32(17) “ . . . to conduct educational programs for

medical assistance program providers, vendors, contractors and recipients designed to limit fraud and abuse within the medical assistance program.”

• These programs will be scheduled as needed by the provider community. Your feedback on this program, and suggestions for new topics are appreciated.

• Next program: Preschool/School Supportive Health Services Program (SSHSP) Medicaid-in-Education

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GOALS OF THIS PROGRAMGOALS OF THIS PROGRAM• Medicaid Redesign Team (MRT) Medicaid Redesign Team (MRT)

changes for dental services changes for dental services • Medicaid rules and policies governing Medicaid rules and policies governing

dentistry servicesdentistry services• Office of Medicaid Inspector General Office of Medicaid Inspector General

reviews of dental practicesreviews of dental practices– Prepayment reviewPrepayment review– System match project auditsSystem match project audits– Credentials verificationCredentials verification

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Medicaid Redesign Team Proposal #17 –Medicaid Redesign Team Proposal #17 – Reduce Fee-for-Service Dental Reduce Fee-for-Service Dental Payment on Select ProceduresPayment on Select Procedures

BackgroundBackground::Medicaid spending for the highest volume dental Medicaid spending for the highest volume dental procedures totaled $237 million for the 2009 procedures totaled $237 million for the 2009 calendar year.calendar year.

Proposal:Proposal: Reduce fee-for service payments to match rates Reduce fee-for service payments to match rates paid by manage care providers on high volume paid by manage care providers on high volume dental procedures.dental procedures.

FY 2011 - 2012FY 2011 - 2012– State Savings: ($27.70) million State Savings: ($27.70) million – Federal Savings: ($55.40) millionFederal Savings: ($55.40) million

FY 2012 – 2013FY 2012 – 2013– State Savings: ($30.20) million State Savings: ($30.20) million – Federal Savings: ($60.40) millionFederal Savings: ($60.40) million

Note: Children’s preventative dental procedures and Orthodonture is excluded. All other codes are subject to reduction.

MRT -11 Reduce FFS Dental Proc...

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THE FOCUS ON DENTAL THE FOCUS ON DENTAL PRACTICEPRACTICEIN FRAUD AND ABUSE IN FRAUD AND ABUSE PROGRAMSPROGRAMS• Attorney General Medicaid Fraud Control Unit/US Department Attorney General Medicaid Fraud Control Unit/US Department

of Justiceof Justice• Federal Office of Inspector General (HHS)Federal Office of Inspector General (HHS)• Office of State ComptrollerOffice of State Comptroller• CMS (Center for Medicare and Medicaid Services) reviewsCMS (Center for Medicare and Medicaid Services) reviews

• Data analytic capabilitiesData analytic capabilities• Managed Care Focus-Delta DentalManaged Care Focus-Delta Dental• Fraud by clients/patients-identity theft, card rental and lendingFraud by clients/patients-identity theft, card rental and lending

• Is it fair? Is it fair? • What can practices do to protect themselves from fraud and What can practices do to protect themselves from fraud and

abuse risks?abuse risks?

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THE FOCUS ON DENTAL THE FOCUS ON DENTAL PRACTICEPRACTICEIN FRAUD AND ABUSE IN FRAUD AND ABUSE PROGRAMSPROGRAMS• Media coverage: “Media coverage: “'Rip-off' dentists clean up'Rip-off' dentists clean up• A single dental clinic that illegally pays low-income A single dental clinic that illegally pays low-income

patients $15 or $20 cash as an enticement to patients $15 or $20 cash as an enticement to undergo routine checkups could rake in more than $2 undergo routine checkups could rake in more than $2 million a year in Medicaid reimbursements from the million a year in Medicaid reimbursements from the state, a Post analysis has found.” New York Post state, a Post analysis has found.” New York Post March 31, 2010March 31, 2010

• “Heartland Dental, Inc.,, agreed to pay $1,650,000 to resolve allegations of improper billing to Illinois Medicaid. (2008) submitting claims for crown buildups, non-covered services, as restorations and claims for surgical extractions which were or should have been simple extractions.

• FORBA Holdings settlement-2010FORBA Holdings settlement-2010

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OTHER AUDIT/INVESTIGATIVE OTHER AUDIT/INVESTIGATIVE RISKSRISKS• New York Attorney General actions New York Attorney General actions

under the New York False Claims Actunder the New York False Claims Act• Whistleblower actions under the New Whistleblower actions under the New

York False Claims Act (these cases York False Claims Act (these cases limited to private entities)limited to private entities)

• Claims under the federal False Claims under the federal False Claims ActClaims Act

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OFFICE OF NY STATE OFFICE OF NY STATE COMPTROLLER (OSC) Dental COMPTROLLER (OSC) Dental AuditsAudits• Recent Dental Audits performed at OSC include;

– Inappropriate Medicaid Payments for Dental Services Provided to Patients with Dentures 03/25/2009 with a follow up report 01/21/2011;

– Medicaid Payments for Dental Consultations 09/30/2010;

– Medicaid Payments for Excessive Dental Services 08/17/2010;

– Inappropriate Medicaid Billings for Dental Services 09/28/2007 & 07/09/2008 with follow up reports on 07/02/2009 & 10/08/2009;

– Inappropriate Medicaid Billings for Dental Sealants 11/26/2007 with a follow up report on 05/07/2009;

– Inappropriate Medicaid Billings for Dental Restorations 12/27/2007 with a follow up report on 05/07/2009.

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HHS Office of Inspector HHS Office of Inspector General Work Plan 2011-Audit General Work Plan 2011-Audit of state expenditures for of state expenditures for dentistrydentistry•We will review Medicaid payments

for dental services to determine whether States have properly claimed the FFP.

• (OAS; W‐00‐10‐31135; W‐00‐11‐31135; various reviews; expected issue date: FY 2011; work in progress)

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CORE MEDICAID CORE MEDICAID REQUIREMENTS FOR ALL REQUIREMENTS FOR ALL PROVIDERSPROVIDERS• (a) to prepare and to maintain contemporaneous records (a) to prepare and to maintain contemporaneous records

demonstrating its right to receive payment under the demonstrating its right to receive payment under the medical assistance program and to keep for a period of six medical assistance program and to keep for a period of six years from the date the care, services or supplies were years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and furnished, all records necessary to disclose the nature and extent of servicesextent of services

• to furnish such records and information, upon requestto furnish such records and information, upon request• Bill for only services which are medically necessary and Bill for only services which are medically necessary and

actually furnished . . .”actually furnished . . .”• Permit audits. . . .of all books and records relating to Permit audits. . . .of all books and records relating to

services furnished and payments received, including services furnished and payments received, including patient histories, case files, and patient-specific datapatient histories, case files, and patient-specific data

• Provide information in relation to any claim . . . Which is Provide information in relation to any claim . . . Which is true, accurate, and complete.true, accurate, and complete.

• Comply with the rules, regulations, and official directives of Comply with the rules, regulations, and official directives of the department.”the department.”

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CORE MEDICAID CORE MEDICAID REQUIREMENTS FOR ALL REQUIREMENTS FOR ALL

PROVIDERSPROVIDERS• Dental records are a legal document that Dental records are a legal document that provide a main source of information about provide a main source of information about what happened and why; what happened and why;

• Dental documentation must Dental documentation must support the support the dental necessity of the service, dental necessity of the service, to what to what extent the service was rendered, and why it extent the service was rendered, and why it was medically justified;was medically justified;

• Accurate and complete documentationAccurate and complete documentation can can ensure better care and ensure better care and increase the increase the chances of full and fair chances of full and fair reimbursement;reimbursement;. .

• Dental Manual identifies the Dental Manual identifies the Record-Keeping Record-Keeping RequirementsRequirements - - General Policy Section page 21General Policy Section page 21

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MEDICAID REGULATIONS AND MEDICAID REGULATIONS AND OFFICIAL DIRECTIVES FOR OFFICIAL DIRECTIVES FOR DENTAL SERVICESDENTAL SERVICES• 18 NYCRR 504.3: Duties of the Provider18 NYCRR 504.3: Duties of the Provider

– ““By enrolling, the provider agrees . . .(i) to By enrolling, the provider agrees . . .(i) to comply with the rules, regulations, and official comply with the rules, regulations, and official directives of the Department.”directives of the Department.”

• Qualifications of Dentists regulation (18 Qualifications of Dentists regulation (18 NYCRR 506.1) NYCRR 506.1)

• Dental Care regulations(18 NYCRR Part Dental Care regulations(18 NYCRR Part 506.2) last amended in 1971506.2) last amended in 1971

• What is an “official directive?”What is an “official directive?”

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““Official Directives”Official Directives”• ““Official directives”Official directives”

– Dental Provider Manual Version 2011-1 (5/15/2011) www.emedny.org/ProviderManuals/Dental/PDFS/Dental_Polwww.emedny.org/ProviderManuals/Dental/PDFS/Dental_Policy_and_Procedure_Manual.pdficy_and_Procedure_Manual.pdf

– Medicaid Updates- Medicaid Updates- http://http://www.health.ny.gov/health_care/medicaid/program/updatelwww.health.ny.gov/health_care/medicaid/program/updatel Sample: Dental Place of Service (POS) Policy and Billing Sample: Dental Place of Service (POS) Policy and Billing GuidanceGuidanceMarch 2011: For dates of service on or after April 1, 2011 -March 2011: For dates of service on or after April 1, 2011 -requires reporting of POS; professional component for requires reporting of POS; professional component for dental services performed at ambulatory surgery, dental services performed at ambulatory surgery, emergency department and inpatient POS will be emergency department and inpatient POS will be reimbursed at 65 percent of the office fee schedule reimbursed at 65 percent of the office fee schedule amount. (Requires accurate reporting of place of service).amount. (Requires accurate reporting of place of service).

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CORE MEDICAID CORE MEDICAID REQUIREMENTS FOR ALL REQUIREMENTS FOR ALL PROVIDERSPROVIDERS

• The dental record should be The dental record should be complete and legiblecomplete and legible;;• The documentation of each patient encounter should The documentation of each patient encounter should

include the date, the reason for the encounter, appropriate include the date, the reason for the encounter, appropriate history and dental exam, review of lab and x-ray data and history and dental exam, review of lab and x-ray data and other ancillary services (where appropriate), an assessment other ancillary services (where appropriate), an assessment , and a treatment plan; , and a treatment plan;

• entries to the dental record should be dated and entries to the dental record should be dated and authenticated;authenticated;– EvaluationsEvaluations– AnesthesiaAnesthesia– RadiographsRadiographs– Testing or diagnostic serviceTesting or diagnostic service– Type of treatmentType of treatment– Service on other intra-oral structuresService on other intra-oral structures– Treatment planTreatment plan– ChartingCharting– Extension notesExtension notes– Failed appointment notesFailed appointment notes– Communication notesCommunication notes

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CORE MEDICAID CORE MEDICAID REQUIREMENTS 18 NYCRR REQUIREMENTS 18 NYCRR 504.3 FOR ALL PROVIDERS504.3 FOR ALL PROVIDERS• Medicaid is payment in full-no balance billingMedicaid is payment in full-no balance billing• Bill for only services which are medically necessary Bill for only services which are medically necessary

and actually furnishedand actually furnished• Bill only for services to eligible personsBill only for services to eligible persons• Permit audits. . . of all books and records relating to Permit audits. . . of all books and records relating to

services furnished and payments received, including services furnished and payments received, including patient histories, case files, and patient-specific datapatient histories, case files, and patient-specific data

• Provide information in relation to any claim . . . Provide information in relation to any claim . . . Which is true, accurate, and complete.Which is true, accurate, and complete.

• ““to comply with the rules, regulations, and official to comply with the rules, regulations, and official directives of the department.”directives of the department.”

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CORE PROFESSIONAL CORE PROFESSIONAL REQUIREMENTS FOR ALL REQUIREMENTS FOR ALL DENTISTSDENTISTS• ““There is one course of conduct which in each and There is one course of conduct which in each and

every profession is known as a matter of common every profession is known as a matter of common knowledge to be improper and unprofessional. That is knowledge to be improper and unprofessional. That is conduct by which, after a professional man has been conduct by which, after a professional man has been licensed by the State, he enters into a partnership in his licensed by the State, he enters into a partnership in his professional work with a layman, by the terms of which professional work with a layman, by the terms of which he divides with the latter, on a percentage basis, he divides with the latter, on a percentage basis, payments made by client or patient for professional payments made by client or patient for professional services rendered.”services rendered.”

• Bell v. Board of RegentsBell v. Board of Regents 65 N.E.2d 184 (Ct. App., 1945).  65 N.E.2d 184 (Ct. App., 1945). • 18 NYCRR 515.2 (b) (5) Bribes and kickbacks-prohibits 18 NYCRR 515.2 (b) (5) Bribes and kickbacks-prohibits

“offering or paying, either directly or indirectly, whether “offering or paying, either directly or indirectly, whether in cash or in kind, . . . In return for referring a client” (or) in cash or in kind, . . . In return for referring a client” (or) “recommending” a provider “recommending” a provider

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PRE-PAYMENT REVIEW PRE-PAYMENT REVIEW PROJECTSPROJECTS• Nancy DelPrado Nancy DelPrado • FocusFocus• Provider interactionProvider interaction• Closing lettersClosing letters• Potential ConsequencesPotential Consequences

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Statewide Dental MatchStatewide Dental Match• Patricia BransonPatricia Branson

– Audit processAudit process

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Statewide Dental MatchStatewide Dental Match• The OMIG initiated a review of Medicaid payments for The OMIG initiated a review of Medicaid payments for

dental services paid between January 1, 2006 through dental services paid between January 1, 2006 through December 31, 2009, which looked at:December 31, 2009, which looked at:– Inappropriate billing for edentulous patients;Inappropriate billing for edentulous patients;– Inappropriate billing after complete upper or lower Inappropriate billing after complete upper or lower

dentures;dentures;– Partial upper dentures billed after complete upper dentures;Partial upper dentures billed after complete upper dentures;– Partial lower dentures bulled after complete lower dentures;Partial lower dentures bulled after complete lower dentures;– Dental services billed fee for service for recipients in skilled Dental services billed fee for service for recipients in skilled

nursing facilities;nursing facilities;– Rebase, reline or repair within the six months of post Rebase, reline or repair within the six months of post

delivery care for dentures;delivery care for dentures;– Consultation procedure billed with no referring provider Consultation procedure billed with no referring provider

information;information;– Consultation procedure billed where the billing provider Consultation procedure billed where the billing provider

matches the referring provider;matches the referring provider;– Single surface restoration claims with surface codes “I” and Single surface restoration claims with surface codes “I” and

“O” or “F” and “B” for the same patient, same tooth, same “O” or “F” and “B” for the same patient, same tooth, same surface, same provider/group within three years. surface, same provider/group within three years.

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Statewide Dental MatchStatewide Dental Match– ““Draft Audit Reports” are issued, Draft Audit Reports” are issued,

what to expect next?what to expect next?•Assigned staff handle all provider Assigned staff handle all provider

phone calls.phone calls.– Final Audit Report or Final Closing Final Audit Report or Final Closing

Letter;Letter;– Result Communicated to provider;Result Communicated to provider;– Agreement or Appeal.Agreement or Appeal.

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Dental Providers CVRs and Dental Providers CVRs and Enrollment Onsite VisitsEnrollment Onsite Visits• Credential verification Reviews (CVR’s) are periodic onsite visits of Credential verification Reviews (CVR’s) are periodic onsite visits of

a providers place of business to ensure overall compliance with a providers place of business to ensure overall compliance with Medicaid regulations. These visits are conducted by the Medicaid Medicaid regulations. These visits are conducted by the Medicaid Program and the Office of the Medicaid Inspector general (OMIG).Program and the Office of the Medicaid Inspector general (OMIG).

• CVR’s assess such areas as;CVR’s assess such areas as;– Provider and staff identification and credentialingProvider and staff identification and credentialing– Physical attributes of the place of businessPhysical attributes of the place of business– Recordkeeping protocols and procedures regarding Medicaid claiming Recordkeeping protocols and procedures regarding Medicaid claiming

• Every effort is made to conduct these visits in a professional and Every effort is made to conduct these visits in a professional and non-obtrusive manner. non-obtrusive manner.

• Investigators conducting these reviews will have a Investigators conducting these reviews will have a letter of letter of introduction signed by the Office of the Medicaid Inspector introduction signed by the Office of the Medicaid Inspector General and a photo identification card. General and a photo identification card.

• Enrollment onsite visits may also occur for providers applying to Enrollment onsite visits may also occur for providers applying to open a new group practice or location in the Medicaid Program. open a new group practice or location in the Medicaid Program.

• If you have any questions regarding a CVR or onsite visit you may If you have any questions regarding a CVR or onsite visit you may call OMIG at 1-518-402-1837. call OMIG at 1-518-402-1837.

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OTHER ISSUESOTHER ISSUES• ““Roster billing”Roster billing”• Card swipeCard swipe• Deceased patientsDeceased patients

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OTHER RISKS IN MEDICAID OTHER RISKS IN MEDICAID PROGRAM FOR PROVIDERSPROGRAM FOR PROVIDERS• Risks can be avoided and managed Risks can be avoided and managed

with basic business processeswith basic business processes

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RISK #1: Using Excluded RISK #1: Using Excluded Persons to Provide Services Persons to Provide Services Reimbursable by MedicaidReimbursable by Medicaid

• See OMIG’s Exclusion Webinar on our See OMIG’s Exclusion Webinar on our website at website at http://www.omig.ny.gov/data/images/http://www.omig.ny.gov/data/images/stories/Webinar/6-8-stories/Webinar/6-8-10_exclusion_webinar_final.ppt10_exclusion_webinar_final.ppt

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Program ExclusionsProgram Exclusions• StatuteStatute• RegulationRegulation• Federal OIG GuidanceFederal OIG Guidance• Federal CMS GuidanceFederal CMS Guidance• State Guidance Mandated by CMSState Guidance Mandated by CMS• Condition of NY provider enrollment or NY state Condition of NY provider enrollment or NY state

contractcontract• Virtually no case law (criminal, civil, or Virtually no case law (criminal, civil, or

administrative) on extent and effect of exclusion administrative) on extent and effect of exclusion

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CMS EXCLUSION CMS EXCLUSION REGULATIONREGULATION• “No payment will be made by Medicare,

Medicaid or any of the other federal health care programs for any item or service furnished by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual who is excluded when the person furnishing such item or service knew or had reason to know of the exclusion.” 42 CFR 1001.1901 (b)

• Focus is not on the relationship but on the payment.

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PROGRAM EXCLUSIONPROGRAM EXCLUSION• Federal authority and requirement on Federal authority and requirement on

providersproviders– No claims based on work of excluded personsNo claims based on work of excluded persons– No “billing through”No “billing through”

• Federal authority and mandate on state Federal authority and mandate on state Medicaid programsMedicaid programs– No state Medicaid claims to CMS based on No state Medicaid claims to CMS based on

work of excluded personswork of excluded persons

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THE NEW YORK STATE THE NEW YORK STATE EXCLUSION REGULATIONEXCLUSION REGULATION• 18 NYCRR 515.518 NYCRR 515.5 Sanctions effect: (a) Sanctions effect: (a)

No payments will be made to or on No payments will be made to or on behalf of any person for the medical behalf of any person for the medical care, services or supplies furnished care, services or supplies furnished by or under the supervision of the by or under the supervision of the person during a period of exclusion person during a period of exclusion or in violation of any condition of or in violation of any condition of participation in the program. participation in the program.

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RISK #2: Failing to Refund RISK #2: Failing to Refund Identified Overpayments to the Identified Overpayments to the Medicaid Program- ACA Medicaid Program- ACA § 6402 6402• ‘‘(d) REPORTING AND RETURNING OF

OVERPAYMENTS—• ‘‘(1) IN GENERAL — If a person has received an

overpayment, the person shall—• ‘‘(A) report and return the overpayment to

the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and

• ‘‘(B) notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment . . .

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ACA ACA § 6402 and False Claims 6402 and False Claims ActAct• Failure to report, refund, and explain Failure to report, refund, and explain

overpayments within 60 days of overpayments within 60 days of identification can give rise to a claim of identification can give rise to a claim of “knowing” failure to repay under the “knowing” failure to repay under the False Claims ActFalse Claims Act

• See OMIG Webinar: See OMIG Webinar: http://www.omig.ny.gov/data/images/stohttp://www.omig.ny.gov/data/images/stories/Webinar/7-14-10_ppaca_webinar.pptries/Webinar/7-14-10_ppaca_webinar.ppt

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RETURNING OVERPAYMENTS IN RETURNING OVERPAYMENTS IN NEW YORK TO THE MEDICAID NEW YORK TO THE MEDICAID PROGRAMPROGRAM

• Report and return the overpayment to the State at the correct address

• In New York, Medicaid overpayments should be returned, reported, and explained to OMIG

• OMIG’s correct address:– Office of the Medicaid Inspector General– 800 North Pearl Street– Albany, New York 12204

• May also use DOH adjustment process for multiple funders through Brad Hutton (BJH08@Health.State.NY.US)

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VOIDS AND SMALL VOIDS AND SMALL OVERPAYMENTSOVERPAYMENTS• Providers may use void process through CSC (the eMedNY claims

system) for smaller or routine claims. A void is submitted to negate a previously paid claim based upon a billing error or late reimbursement by a primary carrier.

• Overpayments of smaller or routine claims which cannot be attributed to billing error or late reimbursement by a primary carrier should be reported to CSC in writing. These should include known mistakes in CSC or DOH billing and payment programs.

• eMedNY call center: 1-800-343-9000, M – F, 7:30 am – 6:00 pm; eMedNY call center: 1-800-343-9000, M – F, 7:30 am – 6:00 pm; email: HIPAADESK3@csc.comemail: HIPAADESK3@csc.com

• See http://www emedny.org/provider manuals for instructions on See http://www emedny.org/provider manuals for instructions on submission of voids.submission of voids.

• NYEIS System also can be used to initiate report and refund process NYEIS System also can be used to initiate report and refund process

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WHAT IS AN WHAT IS AN “OVERPAYMENT”?“OVERPAYMENT”?• ‘‘‘‘(B) OVERPAYMENT—The term (B) OVERPAYMENT—The term

‘‘overpayment’’ means any ‘‘overpayment’’ means any fundsfunds that a that a personperson receives or retains receives or retains under title XVIII (Medicare) or XIX under title XVIII (Medicare) or XIX (Medicaid) to which the person, after (Medicaid) to which the person, after applicable reconciliation, is applicable reconciliation, is not not entitledentitled under such title” under such title”

• ““fundsfunds” not “” not “benefitbenefit””

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WHO MUST RETURN THE WHO MUST RETURN THE OVERPAYMENT?OVERPAYMENT?• A “person” (which includes corporations A “person” (which includes corporations

and partnerships) who has “received” or and partnerships) who has “received” or “retained” the overpayment“retained” the overpayment

• Focus on “receipt”; payment need not Focus on “receipt”; payment need not come directly from Medicaid; if “person” come directly from Medicaid; if “person” “retains” overpayment due the program, “retains” overpayment due the program, violation occurs violation occurs

• ““person” includes a an individual program person” includes a an individual program provider or subcontractorprovider or subcontractor

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WHEN MUST AN WHEN MUST AN OVERPAYMENT BE RETURNED? OVERPAYMENT BE RETURNED? • ACA ACA § 6402(d)(2) 6402(d)(2)

• An overpayment must be reported and An overpayment must be reported and returned . . .by the later of -returned . . .by the later of -– (A) the date which is 60 days after the date (A) the date which is 60 days after the date

on which the overpayment was on which the overpayment was identifiedidentified; ; oror

– (B) the date on which any corresponding (B) the date on which any corresponding cost report is due, if applicablecost report is due, if applicable

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WHEN IS AN OVERPAYMENT WHEN IS AN OVERPAYMENT “IDENTIFIED”?“IDENTIFIED”?• ““identified” for an organization means that the fact of an identified” for an organization means that the fact of an

overpayment, not the amount of the overpayment has been overpayment, not the amount of the overpayment has been identified. (e.g., patient was dead at time service was identified. (e.g., patient was dead at time service was allegedly rendered, APG claim includes service not allegedly rendered, APG claim includes service not rendered, charge master had code crosswalk error)rendered, charge master had code crosswalk error)

• Compare with language from CMS proposed 42 CFR Compare with language from CMS proposed 42 CFR 401.310 overpayment regulation 67 FR 3665 (1/25/02 draft 401.310 overpayment regulation 67 FR 3665 (1/25/02 draft later withdrawn)later withdrawn)– ““If a provider, supplier, or individual identifies a Medicare If a provider, supplier, or individual identifies a Medicare

payment received in excess of amounts payable under the payment received in excess of amounts payable under the Medicare statute and regulations, the provider, supplier, or Medicare statute and regulations, the provider, supplier, or individual must, within 60 days of identifying or learning of the individual must, within 60 days of identifying or learning of the excess payment, return the overpayment to the appropriate excess payment, return the overpayment to the appropriate intermediary or carrier.” intermediary or carrier.”

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WHEN IS AN OVERPAYMENT WHEN IS AN OVERPAYMENT “IDENTIFIED”?“IDENTIFIED”?• Employee or contractor identifies Employee or contractor identifies

overpayment in hotline call or emailoverpayment in hotline call or email• Patient advises that service not receivedPatient advises that service not received• OMIG sends letter re deceased patient, OMIG sends letter re deceased patient,

unlicensed or excluded employee or unlicensed or excluded employee or ordering physicianordering physician

• Qui tamQui tam or government lawsuit or government lawsuit allegations allegations

• Criminal indictment or information Criminal indictment or information

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DOCUMENTING GOOD FAITH DOCUMENTING GOOD FAITH EFFORT TO IDENTIFY EFFORT TO IDENTIFY OVERPAYMENTSOVERPAYMENTS• Create a record to demonstrate to the government Create a record to demonstrate to the government

that your organization collected or attempted to that your organization collected or attempted to address allegations of overpayments address allegations of overpayments – Develop standard form to document employee’s internal Develop standard form to document employee’s internal

disclosure disclosure – Document interviews Document interviews – Document evidence and means to determine if credible Document evidence and means to determine if credible – Record employees involved in deliberations and decisions Record employees involved in deliberations and decisions

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SOME REASONS FOR SOME REASONS FOR OVERPAYMENTSOVERPAYMENTS• Duplicate payments of the same Duplicate payments of the same

service(s). service(s). • Incorrect provider payee. Incorrect provider payee. • Services not actually rendered. Services not actually rendered.

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MORE REASONS FOR MORE REASONS FOR OVERPAYMENTSOVERPAYMENTS• Failure to refund credit balancesFailure to refund credit balances• Excluded ordering or servicing personExcluded ordering or servicing person• Patient deceased Patient deceased • Servicing person lacked required Servicing person lacked required

license or certification (see 18 NYCRR license or certification (see 18 NYCRR 506.1, Qualifications of Dentists) 506.1, Qualifications of Dentists)

• Billing system errorBilling system error

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GOVERNMENT IS USING DATA GOVERNMENT IS USING DATA TO DETECT OVERPAYMENTS TO DETECT OVERPAYMENTS • EXCLUDED PERSONSEXCLUDED PERSONS• DECEASED OR TRANSITIONED DECEASED OR TRANSITIONED

ENROLLEESENROLLEES• DECEASED PROVIDERSDECEASED PROVIDERS• CREDIT BALANCESCREDIT BALANCES• WHAT IS GO-BACK OBLIGATION WHAT IS GO-BACK OBLIGATION

WHEN PROVIDER IS PUT ON NOTICE WHEN PROVIDER IS PUT ON NOTICE THAT SYSTEMS ARE DEFICIENT?THAT SYSTEMS ARE DEFICIENT?

4242

OMIG SELF DISCLOSURE FORM OMIG SELF DISCLOSURE FORM FROM WWW.OMIG.NY.GOVFROM WWW.OMIG.NY.GOV• You must provide written, detailed information

about your self disclosure. This must include a description of the facts and circumstances surrounding the possible fraud, waste, abuse, or inappropriate payment(s), the period involved, the person(s) involved, the legal and program authorities implicated, and the estimated fiscal impact. (Please refer to the OMIG self-disclosure guidance for additional information.)

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RISK #3: Failing to Maintain an RISK #3: Failing to Maintain an “Effective” Compliance “Effective” Compliance Program as Required by 18 Program as Required by 18 NYCRR 521 (if billing over NYCRR 521 (if billing over $500,000 per year)$500,000 per year)• See OMIG Webinar: Evaluating See OMIG Webinar: Evaluating

Effectiveness of Compliance Effectiveness of Compliance ProgramsPrograms

• http://www.omig.ny.gov/data/http://www.omig.ny.gov/data/images/stories/Webinar/images/stories/Webinar/compliance_webinar_11-17-10.pptcompliance_webinar_11-17-10.ppt

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Maintaining an “Effective” Maintaining an “Effective” Compliance ProgramCompliance Program• 18 NYCRR 52118 NYCRR 521• Requires an 8 step effective Requires an 8 step effective

compliance programcompliance program• Requires an annual certification by Requires an annual certification by

December 31 of each yearDecember 31 of each year• Applies to both governments and Applies to both governments and

providers (directly or indirectly)providers (directly or indirectly)

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RISK #4: Failing to Maintain RISK #4: Failing to Maintain and Produce Records and Produce Records Demonstrating Actual Demonstrating Actual Performance of a Reimbursable Performance of a Reimbursable ServiceService

–

4646

Risk #5: Failing to Supervise Risk #5: Failing to Supervise Service Bureaus or Billing Service Bureaus or Billing Companies Submitting Claims Companies Submitting Claims or Receiving Paymentor Receiving Payment• See OMIG Webinar-Third Party Billing See OMIG Webinar-Third Party Billing

in the Medicaid programin the Medicaid program• http://www.omig.ny.gov/data/images/http://www.omig.ny.gov/data/images/

stories/Webinar/1-12-11_third_party_stories/Webinar/1-12-11_third_party_billing_final.pptbilling_final.ppt

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Duty to Supervise Service Duty to Supervise Service Bureaus or Billing Companies Bureaus or Billing Companies Submitting Claims or Receiving Submitting Claims or Receiving PaymentPayment• Who is responsible if the billing Who is responsible if the billing

company makes a mistake?company makes a mistake?• the person or entity on behalf of the person or entity on behalf of

whom the claim is submitted.whom the claim is submitted.

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Questions for Health Care Questions for Health Care Providers About Third-Party Providers About Third-Party BillersBillers• If any non-employee submits your claims, If any non-employee submits your claims,

checks enrollment, or obtains authorizations, checks enrollment, or obtains authorizations, have you received a written representation have you received a written representation that the person or entity has a records that the person or entity has a records preservation policy consistent with EMEDNY-preservation policy consistent with EMEDNY-414601 (i.e., six years from the date of claims 414601 (i.e., six years from the date of claims submission) for material and data your submission) for material and data your organization submits, and 10 NYCRR 69-4.26 organization submits, and 10 NYCRR 69-4.26 requirements (to age 21 for educational requirements (to age 21 for educational records)? records)?

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"Compliance Program "Compliance Program Guidance for Third-Party Guidance for Third-Party Medical Billing Companies,“ 63 Medical Billing Companies,“ 63 FR 70138-70152 (December FR 70138-70152 (December 18, 1998)18, 1998)• billing for items or services not actually documented; billing for items or services not actually documented; • unbundling and upcoding of claims;unbundling and upcoding of claims;• computer software programs that encourage billing computer software programs that encourage billing

personnel to enter data in fields indicating services personnel to enter data in fields indicating services were rendered though not actually performed or were rendered though not actually performed or documented; documented;

• knowing misuse of provider identification numbers knowing misuse of provider identification numbers which results in improper billing in violation of rules which results in improper billing in violation of rules governing reassignment of benefits;governing reassignment of benefits;

• billing company incentives that violate the anti-billing company incentives that violate the anti-kickback statute;kickback statute;

• percentage billing arrangements. percentage billing arrangements.

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New York State Regulation-New York State Regulation-Required enrollment Required enrollment • ““Persons submitting claims, verifying Persons submitting claims, verifying

client eligibility, . . . Except those client eligibility, . . . Except those persons employed by providers persons employed by providers enrolled in the medical assistance enrolled in the medical assistance program, must enroll in the medical program, must enroll in the medical assistance program. . . “ 18 NYCRR assistance program. . . “ 18 NYCRR 504.9504.9

• Is your billing company enrolled? Is your billing company enrolled?

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What can you do to have a positive What can you do to have a positive experience as a Medicaid participating experience as a Medicaid participating provider?provider?• Know the policies, rules and regulations of the Medicaid Know the policies, rules and regulations of the Medicaid

program.program.• Make sure that your staff knows the policies, rules and Make sure that your staff knows the policies, rules and

regulations of the Medicaid program; regulations of the Medicaid program; • Stay current through Stay current through Medicaid UpdateMedicaid Update newsletters and the newsletters and the

eMedNY Web site, eMedNY Web site, www.eMedNY.orgwww.eMedNY.org; ; • Develop treatment plans that are comprehensive and all-Develop treatment plans that are comprehensive and all-

encompassing in scope;encompassing in scope;• Ensure that radiographs are appropriate and of good diagnostic Ensure that radiographs are appropriate and of good diagnostic

quality;quality;• Make sure that each recipient has up-to-date, accurate, full-Make sure that each recipient has up-to-date, accurate, full-

mouth charting of the dentition which correlates with the mouth charting of the dentition which correlates with the radiographs and treatment plans; radiographs and treatment plans;

• When billing for something unusual or more frequently than the When billing for something unusual or more frequently than the norm, bill with an explanation or documentation; norm, bill with an explanation or documentation;

• If you have billing or policy questions, call the dental unit at the If you have billing or policy questions, call the dental unit at the Office of Health Insurance Programs (OHIP) prior to billing for Office of Health Insurance Programs (OHIP) prior to billing for clarification, clarification, 1-800-342-30051-800-342-3005 or or 1-518-474-3575 1-518-474-3575 (menu option (menu option #2) #2)

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FREE STUFF FROM OMIGFREE STUFF FROM OMIG• OMIG website - www.OMIG.ny.govOMIG website - www.OMIG.ny.gov• Mandatory compliance program-hospitals, Mandatory compliance program-hospitals,

managed care, all providers over $500,000/yearmanaged care, all providers over $500,000/year• Over 1500 provider audit reports, detailing findings Over 1500 provider audit reports, detailing findings

in specific industry in specific industry • 66-page work plan issued 4/20/09 - shared with 66-page work plan issued 4/20/09 - shared with

other states and CMS, OIG (new one coming in other states and CMS, OIG (new one coming in July, 2010)July, 2010)

• Listserv (put your name in, get emailed updates)Listserv (put your name in, get emailed updates)• New York excluded provider listNew York excluded provider list• Follow us on Twitter: NYSOMIGFollow us on Twitter: NYSOMIG

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Contact InformationContact Information• Important contact numbers and websites for questions and Important contact numbers and websites for questions and

information;information;

– New York State Office of the Medicaid Inspector General (OMIG)New York State Office of the Medicaid Inspector General (OMIG)• www.OMIG.state.ny.uswww.OMIG.state.ny.us • To Report Medicaid Fraud call – 1-877-873-7283To Report Medicaid Fraud call – 1-877-873-7283• Medicaid Helpline call – 1-800-541-2831Medicaid Helpline call – 1-800-541-2831• OMIG Dental Unit, Questions about CVRs, dental audits, dental OMIG Dental Unit, Questions about CVRs, dental audits, dental

matches, or prepayment claim reviews, call – 1-518-402-1837matches, or prepayment claim reviews, call – 1-518-402-1837– New York State Fiscal Agent, Computer Sciences Corporation New York State Fiscal Agent, Computer Sciences Corporation

(CSC)(CSC)• Medicaid provider manuals and online Links Medicaid provider manuals and online Links www.eMedNY.orgwww.eMedNY.org• For CSC contacts For CSC contacts general@emedny.orggeneral@emedny.org • Inquiries about claim submission process and eligibility issues call Inquiries about claim submission process and eligibility issues call

1-800-343-9000 1-800-343-9000– New York State Department of Health (OHIP)New York State Department of Health (OHIP)

• www.health.state.ny.uswww.health.state.ny.us• OHIP Dental Pended Claims/Prior Approval Unit, inquiries about OHIP Dental Pended Claims/Prior Approval Unit, inquiries about

dental policy, dental pended claims or prior approvals call - 1-800-dental policy, dental pended claims or prior approvals call - 1-800-342-3005 (menu option #2) or 1-518-474-3575 (Menu option #2)342-3005 (menu option #2) or 1-518-474-3575 (Menu option #2)