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NC Department of Health and Human Services DMA MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSW Chief,

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Presentation on theme: "NC Department of Health and Human Services DMA MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSW Chief,"— Presentation transcript:

1 NC Department of Health and Human Services DMA MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section Program Integrity March 7, 2012

2 NC Department of Health and Human Services DMA Program Integrity References/Authority: 42 CFR 438 (Managed Care) 42 CFR 434 (Contracts) 42 CFR 455 and 456 (Program Integrity & Utilization Control) NC Medicaid State Plan NCGS 108A – thru (False Claims) NCGS 108C (Medicaid and Health Choice Provider Requirements) 10A NCAC 22F (Program Integrity)

3 NC Department of Health and Human Services DMA Program Integrity Medicaid Behavioral Health services are provided to recipients in all 100 North Carolina counties. The Division of Medical Assistance has approximately 74,000 providers The Current number of eligible Medicaid recipients is 1.5 million and Health Choice is approximately 130,000 recipients. Over 9,000 Behavioral Health Providers

4 NC Department of Health and Human Services DMA Using the Power of the Medicaid Program to improve the standard of care for Medicaid recipients across the State of North Carolina ----Dr. Craigan Gray, MD, JD, Director, NC DMA

5 NC Department of Health and Human Services DMA Program Integrity Mission Statement It is the mission of Program Integrity to ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupment, and identifying avenues for cost avoidance.

6 NC Department of Health and Human Services DMA Program Integrity Governors Initiatives to address Medicaid fraud and abuse: Signed Senate Bill 675, Prohibit Medicaid Fraud/ Anti-Kickback law (Session Law ) Increased technology to detect and prevent Medicaid fraud and abuse Allocated staff to increase on-site investigations Campaigned to encourage the public and providers to report suspected Medicaid fraud and abuse Increased staff in the Prosecution Unit of Medicaid Investigation Unit-Attorney Generals Office to handle Medicaid fraud and abuse cases

7 NC Department of Health and Human Services DMA Program Integrity Public Concern Fraud and abuse takes money from needy children, the elderly, blind, and disabled. Therefore, identifying, investigating, preventing and recovering money billed improperly to Medicaid is an important mission for this agency Cost taxpayers millions of dollars

8 NC Department of Health and Human Services DMA Program Integrity Public Concern The majority of providers and their billings are honest and accurate. However, one dishonest provider can take thousands of dollars slowly over time by billing for services not rendered or medically unnecessary.

9 NC Department of Health and Human Services DMA MCO Responsibilities MCOs are required to ensure integrity in the Medicaid Managed Care Program and ensure Services are provided in…the best interest of the Recipients. Establish clear policies and procedures for the selection and retention of providers Credentialing and re-credentialing requirements –Policy & procedures –Process –Nondiscriminatory: high risk specialize in conditions that requires costly treatment –Excluded providers

10 NC Department of Health and Human Services DMA MCO Responsibilities: Monitor providers regularly to determine compliance Take corrective action if there is failure to comply Mechanism to detect both utilization and overutilization of services Mechanism to assess the quality and appropriateness of care Make sure providers are credentialed

11 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment: Deny enrollment any person with a 5% or greater direct or indirect ownership interest in the provider –Did not submit timely and accurate information and cooperate with screening –Has been convicted of a criminal offense related to that persons involvement with Federal Health Care program in at least 10 years –Fails to submit sets of fingerprints within 30 days of DMA/CMS request –Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visit

12 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment Verify license Confirm that license has not expired Revalidate the enrollment of all providers at least every five years

13 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment: Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visit Must conduct pre-enrollment and post enrollment site visits of providers who are designated as moderate or high categorical risks to the Medicaid program Must require providers to consent to criminal background checks

14 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment Must check all available Federal databases-determine the exclusion status of providers (Social Security Administrations Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS), and any other such database the Secretary may prescribe.

15 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment (limited, moderate, or high) Limited risk. Verify provider meets all applicable Fed and State requirements Conduct license verification Conduct database checks (pre- and post-enrollment) Moderate risk: All of the Limited screening requirements and Conduct on-site visits

16 NC Department of Health and Human Services DMA MCO Responsibilities Provider Screening & Enrollment High risk: must do limited and moderate screening requirements conduct a criminal background check, and require the submission of finger prints The adjustment of categorical risk levels must happen when a payment suspension is imposed based on credible allegation of fraud, waste or abuse, existing Medicaid overpayment or provider been excluded by the OIG or another states Medicaid program within the previous ten years

17 NC Department of Health and Human Services DMA Provider Responsibilities Meet enrollment criteria & needs of the MCO Be in Good standing with Federal and State Agencies (DMA, DMHDDSAS, DHSR, DOL, DOR, IRS, etc) Not on the OIG exclusion list or any other State exclusion list Comply with all Federal and State regulations Develop corporate compliance plan Conduct regular QA activities and self audits

18 NC Department of Health and Human Services DMA Provider Responsibilities Submit claims that are proper and provide services that are medically necessary Offer training on fraud, waste, and abuse and mechanisms to report incidents or complaints Improve standard of care for consumers Help identify gaps in services and needs of the community served Participate in collaborative efforts to move the managed care delivery system forward

19 NC Department of Health and Human Services DMA Program Integrity Provider Abuse 10A NCAC 22F.0301 Provider abuse includes any incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Medicaid program or its beneficiaries, or which are not reasonable or which are not necessary

20 NC Department of Health and Human Services DMA Program Integrity Provider Fraud Individual participating or non-participating providers who deliberately submit claims for services not actually rendered, or bill for higher-priced services than those actually provided. Providers submission of claims for payment for which there is no supporting documentation available.

21 NC Department of Health and Human Services DMA Program Integrity CONFIDENTIALITY 10A NCAC 22F.0106 All investigations by the North Carolina Division of Medical Assistance concerning allegations of provider fraud, abuse, over-utilization, or inadequate quality of care shall be confidential, and the information contained in the files of such investigations shall be confidential…

22 NC Department of Health and Human Services DMA Program Integrity Trends in Behavioral Health: Overutilization of behavioral health services. Billing for care and services that are provided by an unauthorized, unqualified, or unlicensed person. Limiting access to services Denying access to services

23 NC Department of Health and Human Services DMA Program Integrity Trends in Behavioral Health: Diagnosis does not correspond to treatment rendered Failure to provide and maintain: –proper quality of care, –appropriate care and services, or –medically necessary care and services. Breach of the terms and conditions of participation agreements, or a failure to comply with requirements of certification, or failure to comply with the provisions of the claim form.

24 NC Department of Health and Human Services DMA Program Integrity Trends in Behavioral Health: Altered signatures on documentation Canned Notes Double billing Excessive use of CPT or H Codes Billing for services not rendered Billing for excessive recipients per workday Excessive billing beyond a 24 hour period

25 NC Department of Health and Human Services DMA Program Integrity False Claims Act 31 U.S.C. §§ Imposes liability for person or entity who: Knowingly files a false or fraudulent claim for payments to Medicare, Medicaid, or other federally funded health care program. Knowingly uses false record or statement to obtain payment on a false or fraudulent claim from Medicare, Medicaid or other federally health care program; or Conspires to defraud Medicare, Medicaid or other federally funded health care

26 NC Department of Health and Human Services DMA Program Integrity False Claims Act Medical Assistance Provider False Claims Act (MAPFC) of 1997 makes it unlawful for any Medicaid provider to knowingly make or cause to be made a false claim for payment. Under MAPFC knowingly means that a provider: Has actual knowledge of the information Acts in deliberate ignorance of the truth or falsity of the information; or Acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

27 NC Department of Health and Human Services DMA Program Integrity False Claims Under this Act, 31 U.S.C. Chapter 8, §3801, any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim.

28 NC Department of Health and Human Services DMA Program Integrity Credible Allegation of Fraud 42 CFR 455 – New Federal Rules, March 25, 2011 Credible Allegations of Fraud – Suspension of Medicaid payments

29 NC Department of Health and Human Services DMA Program Integrity A credible allegation of fraud may be an allegation, which has been verified by the State, from any source, including but not limited to the following: –Hotline Complaint –Data Mining –Patterns identified through provider audits, civil false claims cases, and law enforcement investigations.

30 NC Department of Health and Human Services DMA Program Integrity DMA must suspend all Medicaid payments to a provider after the agency determines there is credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual provider or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.

31 NC Department of Health and Human Services DMA Respond to an Investigation Cooperate Comply by producing the documents and information requested Prepare an area for Investigators to conduct the investigation/Audit Two to three days depending on the complaint/issue Entrance Conference, fact finding, and exit conference Administrative Action Reconsideration Review, Contested Case hearing, Superior Court Findings of an investigation may be referred to the Attorney Generals Office The States AGs office and the US Attorneys Office has the authority to investigate and prosecute Medicaid fraud The lack of knowledge is not a defense for fraud.

32 NC Department of Health and Human Services DMA Sanctions & Remedial Measures Termination of providers participation Withholding Payments Recoup overpayments Warning Letters Suspension of a provider for a period of time Probation Prepayment Claims Review Provider Lock-out

33 NC Department of Health and Human Services DMA Other Things to consider: Designate someone to be your compliance officer Develop a corporate compliance plan Training & education for the compliance officer and organization employees on fraud, waste, and abuse Lines of communication between compliance officer and the organization employees Topics to cover: criminal background checks, OIG Exclusions list, professional conduct and ethics, Changes in license status, when to report, etc.

34 NC Department of Health and Human Services DMA Program Integrity Fraud and Abuse Reporting (Provider): Local Managed Care Organizations (LME-MCOs) Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at (English or Spanish) or; Call the Medicaid fraud, waste and program abuse tip-line at DMA-TIP1 ( ); or Call the Health Care Financing Administration Office of Inspector General's Fraud Line at HHS-TIPS; or Call the State Auditor's Waste Line: TIPS; or Complete and submit a Medicaid fraud and abuse confidential online complaint form at: and submit a Medicaid fraud and abuse confidential online complaint form

35 NC Department of Health and Human Services DMA Program Integrity Fraud and Abuse Reporting (Recipient): Local Managed Care Organization (LME-MCOs) Call your County Department of Social Services (DSS) office; orCounty Department of Social Services (DSS) Contact the Division of Medical Assistance by calling the DHHS Customer Service Center at (English or Spanish) or; Call the Medicaid fraud, waste and program abuse tip-line at DMA-TIP1 ( ); or Complete and submit a Medicaid fraud and abuse confidential online complaint form at: and submit a Medicaid fraud and abuse confidential online complaint form

36 NC Department of Health and Human Services DMA QUESTIONS or COMMENTS CONTACT: Patrick O. Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section NC DMA – Program Integrity Phone: (919) Fax: (919)


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