Presentation on theme: "MH/IDD/SA Providers working in a Medicaid Managed Care Environment"— Presentation transcript:
1 MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review SectionProgram IntegrityMarch 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 PlanNCGS 108A – thru (False Claims)NCGS 108C (Medicaid and Health Choice Provider Requirements)10A NCAC 22F (Program Integrity)
3 Program IntegrityMedicaid Behavioral Health services are provided to recipients in all 100 North Carolina counties.The Division of Medical Assistance has approximately 74,000 providersThe 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 IntegrityGovernor’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 abuseAllocated staff to increase on-site investigationsCampaigned to encourage the public and providers to report suspected Medicaid fraud and abuseIncreased 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 agencyCost 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 providersCredentialing and re-credentialing requirementsPolicy & proceduresProcessNondiscriminatory: high risk specialize in conditions that requires costly treatmentExcluded providers
10 MCO Responsibilities: Monitor providers regularly to determine complianceTake corrective action if there is failure to complyMechanism to detect both utilization and overutilization of servicesMechanism to assess the quality and appropriateness of careMake 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 providerDid not submit timely and accurate information and cooperate with screeningHas been convicted of a criminal offense related to that persons involvement with Federal Health Care program in at least 10 yearsFails to submit sets of fingerprints within 30 days of DMA/CMS requestMust 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 & EnrollmentVerify licenseConfirm that license has not expiredRevalidate 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 visitMust conduct pre-enrollment and post enrollment site visits of providers who are designated as moderate or high categorical risks to the Medicaid programMust 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 ResponsibilitiesProvider Screening & Enrollment (limited, moderate, or high)Limited risk.Verify provider meets all applicable Fed and State requirementsConduct license verificationConduct database checks (pre- and post-enrollment)Moderate risk:All of the Limited screening requirements andConduct on-site visits
16 MCO Responsibilities Provider Screening & Enrollment High risk: must do limited and moderate screening requirementsconduct a criminal background check, andrequire the submission of finger printsThe 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 MCOBe 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 listComply with all Federal and State regulationsDevelop corporate compliance planConduct regular QA activities and self audits
18 Provider Responsibilities Submit claims that are proper and provide services that are medically necessaryOffer training on fraud, waste, and abuse and mechanisms to report incidents or complaintsImprove standard of care for consumersHelp identify gaps in services and needs of the community servedParticipate in collaborative efforts to move the managed care delivery system forward
19 Program IntegrityProvider 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 IntegrityProvider 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 IntegrityTrends 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 servicesDenying access to services
23 Trends in Behavioral Health: Program IntegrityTrends in Behavioral Health:Diagnosis does not correspond to treatment renderedFailure to provide and maintain:proper quality of care,appropriate care and services, ormedically 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 IntegrityTrends in Behavioral Health:Altered signatures on documentation“Canned Notes”Double billingExcessive use of CPT or H CodesBilling for services not renderedBilling for excessive recipients per workdayExcessive billing beyond a 24 hour period
25 False Claims Act 31 U.S.C. §§3729-3733 Program IntegrityFalse 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; orConspires 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 informationActs in deliberate ignorance of the truth or falsity of the information; orActs in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.
27 Program IntegrityFalse 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 IntegrityCredible Allegation of Fraud42 CFR 455 –New Federal Rules, March 25, 2011Credible 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 ComplaintData MiningPatterns identified through provider audits, civil false claims cases, and law enforcement investigations.
30 Program IntegrityDMA 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 CooperateComply by producing the documents and information requestedPrepare an area for Investigators to conduct the investigation/AuditTwo to three days depending on the complaint/issueEntrance Conference, fact finding, and exit conferenceAdministrative ActionReconsideration Review, Contested Case hearing, Superior CourtFindings of an investigation may be referred to the Attorney General’s OfficeThe State’s AG’s office and the US Attorney’s Office has the authority to investigate and prosecute Medicaid fraudThe lack of knowledge is not a defense for fraud.
32 Sanctions & Remedial Measures Termination of provider’s participationWithholding PaymentsRecoup overpaymentsWarning LettersSuspension of a provider for a period of timeProbationPrepayment Claims ReviewProvider Lock-out
33 Other Things to consider: Designate someone to be your compliance officerDevelop a corporate compliance planTraining & education for the compliance officer and organization employees on fraud, waste, and abuseLines of communication between compliance officer and the organization employeesTopics 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 IntegrityFraud 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 ( ); orCall the Health Care Financing Administration Office of Inspector General's Fraud Line at HHS-TIPS; orCall the State Auditor's Waste Line: TIPS; orComplete and submit a Medicaid fraud and abuse confidential online complaint form at:
35 Fraud and Abuse Reporting (Recipient): Program IntegrityFraud and Abuse Reporting (Recipient):Local Managed Care Organization (LME-MCOs)Call your County Department of Social Services (DSS) office; orContact 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 ( ); orComplete 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 SectionNC DMA – Program IntegrityPhone: (919)Fax: (919)