PROGRAM INTEGRITY AND PROVIDERS IN MEDICAID

MANAGED CARE

Julia B. Sinclair, MSW, LCSWSr. Director, Quality and Integrity Operations

Smokey Mountain Center

Amanda Maultsby Willett, MS, CHCRegulatory Compliance ManagerEast Carolina Behavioral Health

TRAINING OBJECTIVES 1. Define purpose of Program Integrity in Medicaid Managed Care Organizations

2. Define key Program Integrity related terms and acronyms

3. Describe responsibilities of consumers, provider agencies, LME/MCO, DMA, MID, and federal oversight agencies in regards to Program Integrity activities

4. Differentiate between Program Integrity Investigation and Routine Monitoring

5. Differentiate between types of investigations conducted by the LME/MCO

6. List Program Integrity Referral Sources

7. Differentiate between types of Program Integrity Investigations

8. Define Program Integrity investigation Process

9. List possible outcomes from Program Integrity investigations

10. Identify laws/Regulations/Statues related to Program Integrity

PURPOSE OF PROGRAM INTEGRITY

QUALITY PROVIDERS

• Improved outcomes for consumers

• Reduced oversight for provider

• Confidence in network for LME-MCOs

FISCAL ACCOUNTABILITY

• Investigate provider billing practices

• Ensure dollars are spent in a way that complies with federal and State mandates

• Ensure that tax dollars buy appropriate, quality care for consumers

PI DEFINITIONS AND ACRONYMS

Acronym Meaning

PI Program IntegrityLME/MCO Local Management Entity/Managed Care OrganizationDMA Division of Medical AssistanceMID Medicaid Investigations DivisionCMS The Centers for Medicare & Medicaid ServicesOIG Office of Inspector GeneralEOB Explanation of Benefits

* Additional Acronyms and Definitions have been provided in “Acronym & Definition Document

FRAUD

Fraud is defined by Federal law (42 CFR 455.2) as "an intentional deception or misrepresentation made by a person with the knowledge that the deception

could result in some unauthorized benefit to himself or some other person

ABUSE Abuse is defined by Federal law (42 CFR 455.2) as

provider practices that are inconsistent with sound fiscal business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically

necessary or that fail to meet professionally recognized standards for health care. It also includes recipient

practices that result in unnecessary cost to the Medicaid program.

PROGRAM INTEGRITY IS THE RESPONSIBILITY OF __________

Everyone

• Consumers

• Provider Agencies and their Employees

• LME/MCO and their Employees

• State Oversight Agencies and Employees

• Federal Oversight Agencies and Employees

• Other Stakeholders

CONSUMER’S RESPONSIBILITY

• Use Medicaid responsibly

• Coordination of Benefits (COB)

• individuals should inform provider, LME/MCO and DSS of all insurance coverage

• Identify suspicious practices of providers

• Observation

• Complete EOB process by LME-MCOs

• Identify suspicious behavior of other recipients

PROVIDER AGENCY’S RESPONSIBILITY

• Be familiar with and follow rules/regulations

• Be familiar with and provide services within clinical coverage policies and best practice guidelines

• Coordination of Benefits (COB)

• responsible for gathering all insurance information from the individuals they serve, report this to the LME/MCO and bill third party payors

PROVIDER AGENCY’S RESPONSIBILITY

• Self-audits and self-reporting

• Comply with monitoring and investigations

LME/MCO RESPONSIBILITIES

• Be familiar with and follow rules/regs

• Be familiar with and educate providers and consumers regarding clinical coverage policies and best practice guidelines

• Routinely monitor providers in their provision of services

LME/MCO RESPONSIBILITIES• Coordination of Benefits (COB)

• verify any third party payors and pay only items for which Medicaid is responsible

• Accept and look into all referrals of suspicious practices of recipients and providers

• Maintain integrity and professionalism through referral and investigation process

OTHER AGENCIES’ RESPONSIBILITIES

State Oversight Agency

DMA-PIDivision of Medical Assistance Program Integrity

Law Enforcement Agency

MIDDivision Medicaid Investigations Division

OTHER AGENCIES’ RESPONSIBILITIES

• Create and enforce consistent guidelines for PI

• Enforce and follow federal rules/regulations

• Educate LME/MCOs, providers and consumers regarding PI practice guidelines

• Provide guidance to LME/MCOs in their PI efforts

• Accept referrals of suspicious practices of LME/MCOs, recipients and providers

• Investigate appropriate referrals

FEDERAL OVERSIGHT AGENCIES’ RESPONSIBILITIES

• Centers for Medicare and Medicaid Services (CMS)

• (www.cms.gov)

• “The Centers for Medicare & Medicaid Services (CMS) is committed to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid recipients.”

• 5-year Comprehensive Medicaid Integrity Plan

• Office of Inspector General (OIG)

• www.oig.hhs.gov

• “Since its 1976 establishment, the Office of Inspector General of the U.S. Department of Health & Human Services (HHS) has been at the forefront of the Nation's efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 300 other HHS programs.”

• certifies, and annually recertifies DMA PI

• analyzes PI performance based on 12 performance standards

• develops, implements and publishes the annual workplan

FEDERAL OVERSIGHT AGENCIES’ RESPONSIBILITIES

• Division of Social Services

• Juvenile Justice

• School Systems

• Medical Community

OTHER STAKEHOLDERS’ RESPONSIBILTIES

INVESTIGATION –VS- MONITORING

MONITORING STANDARD OPERATING PROCEDURE

• Types

• Routine

• Focused

• Outcomes

• Report of Findings

• Plans of Correction

• Technical Assistance

• Referrals for investigation

INVESTIGATION

• Based upon an allegation

• Compliance issues suspected

• Higher level sanctions possible

REFERRALS

INTERNAL REFERRALS• Internal Staff

• Electronic Entry

• Website

• Alpha/CI

• Internal Committees

• Data Analytics

• EOB

EXTERNAL REFERRALS • Hotlines

• DHHS

• Mail

• Electronic Entry

• Consumers

• Stakeholder

• Access Line/Call Center

INVESTIGATIONS

CONTINUUM OF INVESTIGATIONS • Grievance

• Provider Network

• Program Integrity

ANNOUNCED

• Desk Review

• Onsite

UNANNOUNCED • Onsite

INVESTIGATION PROCESSES

DESK REVIEW INVESTIGATION PROCESS

1. Screen the Referral

2. Additional Data Mining

3. Determine Type of Investigation Necessary

4. Create an Investigative Plan

DESK REVIEW PROCESS CONTINUED…

5. Determine record sample

6. Create record request and send to provider

7. Inventory/Date stamp/catalog records when they arrive

8. Review records completing documentation

9. What happens when records are not submitted according to request

DESK REVIEW PROCESS CONTINUED…

10. Summarize results

11. Issue Letter

- Notice of Overpayment (copy Finance and PN)

- No Findings Letter

12. Reconsideration when requested

13. Issue final decision (copy Finance and PN)

ANNOUNCED SITE VISIT INVESTIGATION PROCESS

1. Screen the Referral

2. Additional Data Mining

3. Determine Type of Investigation Necessary

4. Verify site of investigation

ANNOUNCED SITE VISIT CONTINUED…5. Create investigation plan

6. Determine record sample

7. Create record request and send to provider with details of onsite (advance notification)

8. Introduction or opening conference onsite

9. Review records completing documentation

10. Exit conference

ANNOUNCED SITE VISIT CONTINUED…

11. Summarize results

12. Issue Letter(copy Finance and PN)

- Notice of Overpayment

- No Findings Letter

13. Reconsideration when requested

14. Issue final decision (copy Finance and PN)

UNANNOUNCED SITE VISIT INVESTIGATION PROCESS

• Same as Announced Site Visit Process without advance notification

• Introduction letter and record request brought to agency site rather than mailing

FOLLOW UP PROCESSES

FOLLOW UP PROCESSES

• Local Reconsiderations

• Provider Payments

• Contested Agency Final Decisions

• Reporting to Other Oversight Agencies

• DMA PI Process

• MID Process

POSSIBLE OUTCOMES

POSSIBLE OUTCOMES OF INVESTIGATIONS

• Sanctions Grid

LAWS/REGULATIONS/STATUES RELATED TO PROGRAM INTEGRITY

FEDERAL ANTI-KICKBACK STATUEHealth care providers cannot offer, pay, solicit, or receive

anything of value for referral of items or services paid for by Medicare, Medicaid, or other federal health care programs

Felony Conviction punishable up to $25,000 in fines, imprisonment, or both

FALSE CLAIMS ACT (FCA)

Law that was established to punish persons or entities that file false or fraudulent claims for payment by government

agencies

Financial penalties: $5,000 - $11,000 per claim

WHISTLE BLOWER ACT

Anyone who reports fraud and/or abuse to the federal government can claim protection from retaliation under the Whistle blower Act.

Additionally, if any money is recovered as a result of the report filed by a whistle blower, that person could file a lawsuit that can result in

receiving a portion of the recovered money.

DEFICIT REDUCTION ACT

Designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries.

Requires compliance for continued participation in the programs by agencies providing billing five million (5mm) or more annually.

Felony conviction and a fine up to $25,000 and/or imprisonment for no more than 5 years if false statements

CIVIL MONETARY PENALTIES LAW

Intended to prevent health care providers from improperly influencing how Medicare and Medicaid consumers select their care provider

Penalties are imposed when entities or individuals offer or give something of value to Medicare/Medicaid consumers so that they will choose a

particular provider or supplier

Fines of up to $50,000 per wrongful action

HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)

Regulates the way certain health plans, health providers, and health clearinghouses (covered entities) handle Protected Health Information (PHI). Creates Federal standards for maintaining the confidentiality of

PHI and governs its use and disclosure

Civil penalties up to $100/violation up to $25,000/year

Criminal penalties $50,000 and 1yr imprisonment up to $250,000 and 10yrs imprisonment

RESOURCES• Key Laws, Regulations, Statues Grid

• Definition and Acronym Spreadsheet

• LME/MCO Program Integrity Contact Information

• Standardized Sanctions Grid

• CMS Fact Sheet

• OIG Work Plan Example Sheet

QUESTIONS??