1. 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. 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. 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. “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. 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. Program Integrity
Governor’s 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 General’s Office to handle Medicaid fraud and abuse cases

7. 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. 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. MCO Responsibilities Policy & procedures Process
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. 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. 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. MCO Responsibilities Verify license
Provider Screening & Enrollment
Verify license
Confirm that license has not expired
Revalidate the enrollment of all providers at least every five years

13. 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. MCO Responsibilities Provider Screening & Enrollment
Must check all available Federal databases-determine the exclusion status of providers (Social Security Administration’s 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. 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. 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. 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. 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. Program Integrity
Provider Abuse 10A NCAC 22F 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. 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. 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. Trends in Behavioral Health:
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. Trends in Behavioral Health:
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. Trends in Behavioral Health:
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. False Claims Act 31 U.S.C. §§3729-3733
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. 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. 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. Credible Allegation of Fraud
Program Integrity
Credible Allegation of Fraud
42 CFR 455 –
New Federal Rules, March 25, 2011
Credible Allegations of Fraud – Suspension of Medicaid payments

29. Program Integrity Hotline Complaint Data Mining
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. 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. 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 General’s Office
The State’s AG’s office and the US Attorney’s Office has the authority to investigate and prosecute Medicaid fraud
The lack of knowledge is not a defense for fraud.

32. Sanctions & Remedial Measures
Termination of provider’s participation
Withholding Payments
Recoup overpayments
Warning Letters
Suspension of a provider for a period of time
Probation
Prepayment Claims Review
Provider Lock-out

33. 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. Fraud and Abuse Reporting (Provider):
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:

35. Fraud and Abuse Reporting (Recipient):
Program Integrity
Fraud and Abuse Reporting (Recipient):
Local Managed Care Organization (LME-MCOs)
Call your County Department of Social Services (DSS) office; or
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:

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