METRO CHAPTER HFMA METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL JOSEPH A. LEVI ANNUAL

INSTITUTEINSTITUTEELMHURST, NY 3/11/11ELMHURST, NY 3/11/11

OMIG-NO PROVIDER LEFT OMIG-NO PROVIDER LEFT BEHINDBEHIND

James G. SheehanJames G. Sheehan

Medicaid Inspector GeneralMedicaid Inspector General

James.Sheehan@OMIG.NY.GOJames.Sheehan@OMIG.NY.GOVV

2011-Governor Cuomo: ”New 2011-Governor Cuomo: ”New York is at a crossroads”York is at a crossroads”

• Budget challenges-$9-$10 billion Budget challenges-$9-$10 billion deficit projectiondeficit projection

• MRT (Medicaid Redesign Team) MRT (Medicaid Redesign Team)

• 79 agreed-upon Medicaid proposals 79 agreed-upon Medicaid proposals now before Legislaturenow before Legislature

• Budget deadline-April 1 Budget deadline-April 1

CORE QUESTIONS IN PROGRAM CORE QUESTIONS IN PROGRAM INTEGRITYINTEGRITY• How do we determine whether NY Medicaid How do we determine whether NY Medicaid

and its patients get the services it is paying and its patients get the services it is paying for? (actually rendered, ordered, needed, for? (actually rendered, ordered, needed, documented, minimum quality) documented, minimum quality)

• Do NY Medicaid providers comply with their Do NY Medicaid providers comply with their contractual requirements for payment? contractual requirements for payment?

• How do we identify the providers most likely How do we identify the providers most likely to fail in their compliance and patient care to fail in their compliance and patient care obligations? obligations?

• What we do with these identified providers?What we do with these identified providers?

How do we determine whether How do we determine whether NY Medicaid and its patients NY Medicaid and its patients get the services it is paying get the services it is paying for? for? • Existing approaches:Existing approaches:

– Field audits/desk audits (is there a physician Field audits/desk audits (is there a physician order for the service? Is there a record the order for the service? Is there a record the patient actually received the service?) patient actually received the service?)

– Data matches-billing for deceased patients, Data matches-billing for deceased patients, billing for home health during hospital staybilling for home health during hospital stay

– Third party payor reviews-are we paying for Third party payor reviews-are we paying for something someone else should pay for? something someone else should pay for?

How do we determine whether How do we determine whether NY Medicaid and its patients NY Medicaid and its patients get the services it is paying get the services it is paying for?for?• Newer approachesNewer approaches

– Clinical audits-do the services rendered Clinical audits-do the services rendered and billed map against patient assessment and billed map against patient assessment and treatment plan of care? Why are and treatment plan of care? Why are patients with no prior diabetes diagnosis patients with no prior diabetes diagnosis getting test strips? Has a physician who getting test strips? Has a physician who ordered $10 million in home health ordered $10 million in home health services actually seen and treated the services actually seen and treated the patients for whom services are ordered?patients for whom services are ordered?

How do we determine whether How do we determine whether NY Medicaid and its patients NY Medicaid and its patients get the services it is paying get the services it is paying for?for?• Newer approachesNewer approaches

• Data analysis on third party claim Data analysis on third party claim payment information received from payment information received from private payors and Medicareprivate payors and Medicare– Who got paid twiceWho got paid twice– Who charged us after payment in full by Who charged us after payment in full by

private payorprivate payor– Who kept the money? Who kept the money?

How do we determine whether How do we determine whether NY Medicaid and its patients NY Medicaid and its patients get the services it is paying get the services it is paying for? for? • Newer approachesNewer approaches

– Medicaid Integrity Contractor (required Medicaid Integrity Contractor (required by feds)by feds)

– Medicaid RAC (required by feds)Medicaid RAC (required by feds)– Salient data miningSalient data mining

•Geographic mappingGeographic mapping•Time mappingTime mapping•Network analysisNetwork analysis•Claim denial analysisClaim denial analysis

Do NY Medicaid providers Do NY Medicaid providers comply with their contractual comply with their contractual requirements for payment?requirements for payment?• Credentials Verification ReviewsCredentials Verification Reviews

• Licenses, consLicenses, cons

• CertificationsCertifications

• Excluded persons ordering or providingExcluded persons ordering or providing

• Real addresses, real owners, service Real addresses, real owners, service provided by billing entity?provided by billing entity?

• Doctor “flophouses” rented by weekDoctor “flophouses” rented by week

• Service bureausService bureaus

How do we identify the How do we identify the providers most likely to fail in providers most likely to fail in their compliance and patient their compliance and patient care obligations? care obligations? • Investigator’s technique: ask them Investigator’s technique: ask them

when you already know the answerwhen you already know the answer

• Compliance technique: testingCompliance technique: testing

• ““No provider left behind”No provider left behind”

THE OMIG STORY-NO THE OMIG STORY-NO PROVIDER LEFT BEHINDPROVIDER LEFT BEHIND• New York’s Mandatory Compliance New York’s Mandatory Compliance

ProgramProgram• Every Medicaid provider which receives or Every Medicaid provider which receives or

orders more than $500,000 in Medicaid orders more than $500,000 in Medicaid reimbursed services must have an effective reimbursed services must have an effective compliance program including 8 elementscompliance program including 8 elements

• Every Medicaid provider subject to Every Medicaid provider subject to requirements:requirements:– As of October 1, 2009 must have effective As of October 1, 2009 must have effective

compliance program compliance program – As of December 31, 2009 must certify that it As of December 31, 2009 must certify that it

has an effective compliance program has an effective compliance program

THE OMIG STORY-NO THE OMIG STORY-NO PROVIDER LEFT BEHIND PROVIDER LEFT BEHIND

• Every Medicaid provider which Every Medicaid provider which receives or orders more than receives or orders more than $500,000 in Medicaid reimbursed $500,000 in Medicaid reimbursed services in 12 months must have an services in 12 months must have an effective compliance program effective compliance program including 8 elementsincluding 8 elements

FIRST COMPLIANCE YEAR-FIRST COMPLIANCE YEAR-2010-EASY EXAM-SIGN YOUR 2010-EASY EXAM-SIGN YOUR NAME, SCORE 100NAME, SCORE 100• Every Medicaid provider subject to Every Medicaid provider subject to

requirement must certify during requirement must certify during December 2009 that it has an December 2009 that it has an effective compliance program effective compliance program

HOW DID NY PROVIDERS DO HOW DID NY PROVIDERS DO ON THE EASY EXAM?ON THE EASY EXAM?

• AS OF APRIL 1, 2010, THREE AS OF APRIL 1, 2010, THREE MONTHS AFTER THE REQUIRED MONTHS AFTER THE REQUIRED “SIGN YOUR NAME, GET 100” Exam. . “SIGN YOUR NAME, GET 100” Exam. . ..

HOW DID NY PROVIDERS DO HOW DID NY PROVIDERS DO ON THE EASY EXAM?ON THE EASY EXAM?

• 50% flunked!50% flunked!

Options when 50% flunk “no Options when 50% flunk “no provider left behind”provider left behind”

• Blame the students (providers)Blame the students (providers)

• Blame the teachers (OMIG)Blame the teachers (OMIG)

• Blame the parents (Board, CEO)Blame the parents (Board, CEO)

• Figure out how to do better Figure out how to do better

EASY EXAM-YOU FLUNKED THE EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL TELL YOU FIRST TIME, WE WILL TELL YOU THE ANSWER-GIVE IT BACK TO THE ANSWER-GIVE IT BACK TO USUS• Letters to every non-certifying provider over Letters to every non-certifying provider over

$500,000 per year$500,000 per year

• Personal visits and phone callsPersonal visits and phone calls

• Webinars and trade association Webinars and trade association presentationspresentations

• Detailed website instructions, discussion of Detailed website instructions, discussion of consequences of non-certificationconsequences of non-certification

• Extended deadline to October 1Extended deadline to October 1

• What happened?What happened?

EASY EXAM-YOU FLUNKED THE EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL TELL YOU FIRST TIME, WE WILL TELL YOU THE ANSWER- JUST GIVE IT THE ANSWER- JUST GIVE IT BACK TO USBACK TO US

• 20% still flunked!20% still flunked!

SECOND COMPLIANCE EXAM-SECOND COMPLIANCE EXAM-2011-EASY EXAM-SIGN YOUR 2011-EASY EXAM-SIGN YOUR NAME, READ OUR CHEAT NAME, READ OUR CHEAT SHEET AND FOLLOW IT, SCORE SHEET AND FOLLOW IT, SCORE 100100• Show me the cheat sheet . . .Show me the cheat sheet . . .

New York State Social Services Law Section 363-d.Subsection 2New York State Social Services Law Section 363-d.Subsection 2Certification by December 31 of each year-”effective”Certification by December 31 of each year-”effective”

18 NYCRR Section 521.3 (c)18 NYCRR Section 521.3 (c)

A compliance program shall include the following 8 elements:A compliance program shall include the following 8 elements:

• Element 1: Element 1: Written Policies and ProceduresWritten Policies and Procedures• Element 2: Element 2: Designation of Compliance OfficerDesignation of Compliance Officer• Element 3: Element 3: Training and EducationTraining and Education• Element 4: Element 4: Communication lines to the Compliance OfficerCommunication lines to the Compliance Officer• Element 5: Element 5: Disciplinary PoliciesDisciplinary Policies• Element 6: Element 6: Identification of Compliance Risk Areas and non-Identification of Compliance Risk Areas and non-

compliancecompliance• Element 7: Element 7: Responding to Compliance IssuesResponding to Compliance Issues• Element 8:Element 8: Policy of Non-Intimidation and Non-RetaliationPolicy of Non-Intimidation and Non-Retaliation

New York: Eight Elements of Compliance Program; Certification

of Compliance

New York Compliance New York Compliance Measurement ToolMeasurement Tool

• Cited by CMS as modelCited by CMS as model

• Available on OMIG websiteAvailable on OMIG website– www.OMIG.NY.Gov

2011 NEW YORK 2011 NEW YORK COMPLIANCECOMPLIANCE• How are we doing in 2011?How are we doing in 2011?

– Somewhat better, but not as well as we Somewhat better, but not as well as we hoped-even with organizations hoped-even with organizations contacted in 2010contacted in 2010

– OMIG is now doing on-site compliance OMIG is now doing on-site compliance reviews to assess the compliance reviews to assess the compliance programs of specific providersprograms of specific providers

– Start with good ones for modelingStart with good ones for modeling– Move to weaker ones for interventionMove to weaker ones for intervention

2011 NEW YORK 2011 NEW YORK COMPLIANCECOMPLIANCE• Universe of Providers by Provider ID paid or Universe of Providers by Provider ID paid or

ordered over $1 million: 19,885ordered over $1 million: 19,885

• Providers by Provider ID paid or ordered Providers by Provider ID paid or ordered over $1 million not certified (as of 3/10/11) over $1 million not certified (as of 3/10/11) 4,352 (22%) 4,352 (22%)

• Universe of Providers by Provider ID paid or Universe of Providers by Provider ID paid or ordered over $5 million not certified: 234 ordered over $5 million not certified: 234

• Small number of ordered over $1 million Small number of ordered over $1 million

WHAT SHOULD OMIG DO WITH WHAT SHOULD OMIG DO WITH ORGANIZATIONS WHICH DO ORGANIZATIONS WHICH DO NOT PASS THE EXAM?NOT PASS THE EXAM?• If you can’t pass an exam where you get a If you can’t pass an exam where you get a

perfect score for signing your name, and we perfect score for signing your name, and we give you the correct answers, you probably give you the correct answers, you probably aren’t doing a great job with your core aren’t doing a great job with your core health care mission or correct billing either health care mission or correct billing either

• If you contract or have business If you contract or have business relationships with organizations that do not relationships with organizations that do not or cannot certify, they may not be doing a or cannot certify, they may not be doing a great job with their contractual and care great job with their contractual and care obligations to you and patients either obligations to you and patients either

How else do we identify the How else do we identify the providers most likely to fail in providers most likely to fail in their compliance and patient their compliance and patient care obligations?care obligations?• Affordable Care Act Section 6402Affordable Care Act Section 6402

• Report, refund, and explain identified Report, refund, and explain identified overpayments within 60 days of identificationoverpayments within 60 days of identification

• Knowing failure to report= False Claims Act Knowing failure to report= False Claims Act violationviolation

• ““Zero is a bad number”Zero is a bad number”

• 227 reports in 2010 is a good number227 reports in 2010 is a good number

• Use self-disclosure protocol on OMIG websiteUse self-disclosure protocol on OMIG website

How else do we identify the How else do we identify the providers most likely to fail in providers most likely to fail in their compliance and patient their compliance and patient care obligations?care obligations?• If they can’t pass the OMIG exam, If they can’t pass the OMIG exam,

which requires signing your name which requires signing your name and reading the cheat sheet, how are and reading the cheat sheet, how are they doing on the IRS exam?they doing on the IRS exam?

IRS Form 990 Questions for Non-Profits on Governance Policies

NEW YORK: MEASURING NEW YORK: MEASURING COMPLIANCE PROGRAMSCOMPLIANCE PROGRAMS

• Telephone callsTelephone calls• ““Please connect me with your compliance officer”Please connect me with your compliance officer”• ““How do you check for excluded persons among How do you check for excluded persons among

employees and contractors?”employees and contractors?”• ““We have not received your certification; could We have not received your certification; could

you send me a copy?”you send me a copy?”• ““How often do you meet with the Board or a How often do you meet with the Board or a

board committee?”board committee?”• ““Can we get a copy of your most recent IRS-990”Can we get a copy of your most recent IRS-990”

How else do we identify the How else do we identify the providers most likely to fail in providers most likely to fail in their compliance and patient their compliance and patient care obligations?care obligations?• Relationship mapping of problem Relationship mapping of problem

providersproviders• ““And then what happened?” followups And then what happened?” followups

to match projects, third party liability, to match projects, third party liability, audits for corrective actionaudits for corrective action

• Conflict and exception reports in Conflict and exception reports in home healthhome health

• hotlinehotline

What can we do with the What can we do with the identified providers who identified providers who cannot meet their compliance cannot meet their compliance obligations?obligations?• Call or write and ask whyCall or write and ask why• Post names of non-certifiersPost names of non-certifiers• Reduce audit, investigative efforts on compliant Reduce audit, investigative efforts on compliant

organizations (and encourage other enforcement organizations (and encourage other enforcement and regulatory entities to do so) and regulatory entities to do so)

• Terminate audits promptly where strong evidence Terminate audits promptly where strong evidence of complianceof compliance

• Increase audit, investigative, data analytic efforts Increase audit, investigative, data analytic efforts on less compliant organizations on less compliant organizations

• Look for common factors and relationships among Look for common factors and relationships among less compliant providers (e.g., CEO indicted by US less compliant providers (e.g., CEO indicted by US Department of Justice) Department of Justice)

AUDITING “EFFECTIVE” AUDITING “EFFECTIVE” COMPLIANCE PROGRAMSCOMPLIANCE PROGRAMS• Who is the compliance officer?Who is the compliance officer?• To whom do they report?To whom do they report?• Do employees and vendors know about the Do employees and vendors know about the

compliance program?compliance program?• Who does billing? How accurate is it?Who does billing? How accurate is it?• Contingency fee contracting for coding and billingContingency fee contracting for coding and billing• FMV reviews of physician paymentsFMV reviews of physician payments• Conflicts of interestConflicts of interest• Relationships with non-profits and the IRS form Relationships with non-profits and the IRS form

990990

OMIG PLANS TO INCREASE ITS OMIG PLANS TO INCREASE ITS FOCUS ON COMPLIANCE-FOCUS ON COMPLIANCE-CHALLENGED ORGANIZATIONS CHALLENGED ORGANIZATIONS • AuditsAudits

• Data match followupData match followup

• Salient analysis (geography, Salient analysis (geography, chronology, relationships)chronology, relationships)

• InvestigationsInvestigations

• ExclusionsExclusions

WHAT SHOULD BUSINESS WHAT SHOULD BUSINESS PARTNERS DO WITH PARTNERS DO WITH ORGANIZATIONS WHICH DO ORGANIZATIONS WHICH DO NOT CERTIFY?NOT CERTIFY?

• If you can’t pass an exam where you If you can’t pass an exam where you get a perfect score for signing your get a perfect score for signing your name, and OMIG gives you the name, and OMIG gives you the correct answers, you probably aren’t correct answers, you probably aren’t doing a great job with your core doing a great job with your core health care mission and your health care mission and your contractual and partner contractual and partner responsibilities either responsibilities either

WHAT SHOULD BUSINESS WHAT SHOULD BUSINESS PARTNERS DO WITH PARTNERS DO WITH ORGANIZATIONS WHICH DO ORGANIZATIONS WHICH DO NOT CERTIFY?NOT CERTIFY?• Call or write and ask whyCall or write and ask why• Raise issue to higher level in organizationRaise issue to higher level in organization• Investigator’s technique: ask them when Investigator’s technique: ask them when

you already know the answeryou already know the answer• Compliance requirementsCompliance requirements• Element 6: Element 6: Identification of Compliance Risk Identification of Compliance Risk

Areas and non-complianceAreas and non-compliance• Element 7: Element 7: Responding to Compliance Responding to Compliance

IssuesIssues

• Model compliance programs-hospitals, managed Model compliance programs-hospitals, managed care (coming soon) and Compliance Alertscare (coming soon) and Compliance Alerts

• Over 2000 provider audit reports, detailing Over 2000 provider audit reports, detailing findings in specific industry findings in specific industry

• Annual work plansAnnual work plans

• New York excluded provider list New York excluded provider list

• Self-Disclosure protocol Self-Disclosure protocol

• Corporate Integrity AgreementsCorporate Integrity Agreements

• ListservListserv

• Link to sites for all 18 states which currently Link to sites for all 18 states which currently publish their state exclusion listspublish their state exclusion lists

FREE STUFF!FREE STUFF!www.omig.ny.govwww.omig.ny.gov