Presentation on theme: "Today’s Objectives Describe OMIG’s new approach to payment recapture"— Presentation transcript:
0 OMIG\HMS Integrated Reviews & Provider Portal Cerebral Palsy Associations of New York StateApril 2011
1 Today’s Objectives Describe OMIG’s new approach to payment recapture Demonstrate how this approach can help optimize recoveries and minimize abrasionProvide an overview of the OMIG/HMS Provider PortalWe have three objectives today.I’m going to talk about a new and innovative approach to “payment capture”I’ll talk about how this approach can help Medicaid agencies optimize recoveries, minimize abrasion, and prevent future overpayments.And, finally, I’ll give you some specific ideas you can start to implement right away to impact your results.11
2 Where We Are Now TPL PI Provider self-disclosure Data matching Cost avoidanceThird party reviewsEstate and casualty recoveryDirect billingDisallowancesTPLPIProvider self-disclosureOnsite and desk reviewsCredit balance reviewsData miningLong-term care reviewInstitutional reviewsAs we began to approach our recovery efforts in a more holistic way, the line between some of our TPL efforts and some of our PI efforts began to blur.So, for example, our onsite and desk reviews, our data mining efforts, and our long-term care reviews were both addressing TPL and PI overpayments.We enacted changes to NYS Insurance and Social Services laws in 2009 pursuant to the Deficit Reduction Act of 2005 in order to optimize our recovery opportunities and obtain additional third party payor data: specifically, paid claims. Paid claims will play a large role in shaping our PI programs and I will talk more about this later on in the slide.In the meantime, adopting the DRA and how we used that regulation to improve our positioning on Program Integrity is yet another illustration that there is a lot to be gained from the integrated approach.Where TPL and Program Integrity efforts are coordinated, there’s more opportunity to increase recoveries, save costs, and prevent provider abrasion.
3 Where We Are Headed INTEGRATION Provider disclosure Cost avoidance Payment integrity reviewse-ReviewsData matchingThird party reviewsInstitutional reviewsEstate and casualty recoveryFraud referralsOnsite and desk reviewsDisallowancesNew York is in the process of enhancing its payment capture efforts through integrated and streamlined Reviews. Key objectives:1. Multiple overpayment reasons (minimizes provider abrasion)2. Improve provider education3. Tools to stop the bleeding (sentinel effect, better compliance)Let me take you through our vision.Data miningLong-term care reviewsDirect billingFree standing clinic reviewsProvider scoring
4 ACA Increases Focus on Program Section 6402(a) of Affordable Care Act (ACA) requires providers to “report and return” overpaymentsSection 6411(a) requires states to establish contract(s) with one or more Medicaid Recovery Audit ContractorsFunding to combat fraud, waste and abuseNYS OMIG was working on an integrated solution before PPACA.The Patient Protection and Affordable Care Act (PPACA) includes a number of requirements that directly impact “payment recapture” programs.One, PPACA mandates provider self-disclosure and the return of “identified” overpayments within 60 days. Providers who fail to do so face potential liability under the Fraud enforcement and recovery Act of New York State is assessing how to enforce provider disclosures as part of our integrated approach to identifying overpayments. We’ll talk more about this a little later on.Two, PPACA requires all Medicaid programs to contract with at least one RAC on a contingency basis by the end of this calendar year.Three, PPACA provides $700 million over the next decade in new funds to fight fraud. CMS will be holding payors increasingly responsible for making sure that Federal dollars are spent appropriately.All of these changes, especially the first two, impact every program integrity and compliance program; and each program will likely have to make some adjustments. At the same time, we view these changes as opportunities to strengthen PI and compliance programs. For example, the mandatory self-disclosure rule -- New York OMIG views this as a “game changer.” With a federal regulation that places duties on providers to return overpayments OMIG will be shifting focus from pure recoveries where OMIG drove the identification and recovery to a more compliance approach to ensuring providers take this mandate seriously.Together, all of these factors are driving Medicaid efforts to identify and collect on overpayments. In other words, these regulations – and particularly mandatory self-disclosure – represent a paradigm shift to clearly place duties on providers to “report and return” Medicaid overpayments. NY is making program adjustments to take advantage of this shift.
5 NY Medicaid RAC Program OMIG has designated HMS as the New York Medicaid RAC with CMS’s approval of the SPAIntegrated approach shares data across programsMaximize identification of payment issuesReduce future overpaymentsMinimize provider burdenThe “integrated approach” will be a central piece to New York OMIG Medicaid RAC ProgramAgain, we are already starting to benefit from this approach, with more recoveries. And we’re doing it without experiencing provider appeals.And, finally, with CMS’s mandate for contingency fee-based Medicaid RAC programs, it’s possible that many of these efforts will meet CMS’s requirements under PPACA.
6 Integrated ApproachI would like to spend a minute and talk about the front end edits within MMIS and provide a point of reference to where our integrated approach fits within the big picture. As everyone here knows, providers submit claims to MMIS and the system begins adjudicating claims. During adjudication MMIS checks for:Medicaid EligibilityCodingThird Party resources-And just to give you an idea, NY MMIS has over one million lines of codes.By and large, MMIS flags most issues during adjudication and denies erroneous claims. However, not every issue can be identified at the point of adjudication – in fact certain types of overpayments don’t become an overpayment until after the fact. This is true of any claiming platform and further supported by the fact that every Medicaid program and every payor for that matter has programs aimed at recovering overpayments.The following describes how OMIG is addressing this universal need through an integrated approach.
7 Integrated ApproachUpon adjudication, claims are paid
8 Integrated ApproachThe “integrated approach” begins with Provider Self-Disclosure. Providers are responsible for reviewing Medicaid payments and ensuring that they received payments for the correct service and for the correct amountOMIG has begun to mail letters prompting providers to conduct a self-review and disclose confirmed overpaymentsOMIG plans to leverage a current vendor to develop a web-based portalGive providers a self-service tool for disclosing overpaymentsPortal to capture refund reasons and amounts electronicallyPlan is to allow providers ability to query claims data in order to minimize data entry while improving accuracy of self-disclosuresOther tools will be available to allow the process to be as simple as possiblePlan is to leverage the existing registration information on the Provider Website for Third Party Reviews – 1,703 registered users, 941 unique provider ID #s – and also conduct outreach campaigns4. Let’s talk for a minute about the interpretation of the PPACA rule that says that an overpayment must be reported and returned by the later of (a) the data which is 60 days after the date on which the overpayment was “identified” or (b) the date on which any corresponding cost report is due, if applicable.DISCUSS OMIG INTERPRETATION BRIEFLYProvider billing and payment system shows credit balance after posting of paymentsEmployee or contractor identifies overpayment in hotline call or to providerQui tam or government lawsuit allegations disclosed to providerCriminal indictment or information88
9 Integrated ApproachOMIG continues to review provider Aged Trial Balance reports, selecting providers for onsite and desk reviews. We are notifying providers by mail, and asking them to supply additional reports necessary for the review. Provider attestation will be required at review closing.We also conduct data mining to determine whether there are potential overpayments not disclosed on provider ATBs.We continue to run existing algorithms while developing new onesTargeted claims are reviewed through onsite or desk reviews—or along with the ATB review99
10 Integrated ApproachThe next step in this approach are what we call “e-reviews.” It’s worth spending a little time on this.We are launching a game-changing approach to data mining, where we’ll be using external data to identify overpayments in a more precise way.GO TO NEXT SLIDE
11 e-Reviews and Data Mining Uses paid claims data from third party payors and other external dataCommercialMedicareProvider A/R (Credit & Debit Balances)Allows for validation of overpayment at time of data miningNotifies providers via mail and portalRecoveries may be initiated electronically through MMISWe are in the process of obtaining Paid Claims data from more than 16 payors, and we are pursuing Medicare paid claims data.By using external data, we can validate overpayments at the point of data mining.Providers will be notified through mail—and eventually through the web-based portal.This initiative expands the scope of our data mining efforts to other provider types, includingStand-alone clinicsMedical suppliersPharmacyMedi-Medi on steroids1111
12 e-Reviews and Data Mining (cont.) More emphasis on provider compliance and program oversightEach overpayment is reviewed at the claim levelDrives the integration of TPL and PI through data mining[click when you are ready to highlight the last bullet]NEED TO UPDATE NOTES ON THIS SLIDEThis slide is about “why” eReview and Data Mining makes sense - e.g. 1) gives the state tremendous leverage; 2) shifting from pure recovery programs to compliance programs.1212
14 Integrated ApproachWho’s showing up across multiple overpayment scenariosWill be looking for aberrant behaviorsFrequency of self-disclosureOverpayment reasonsWho finds the overpayments (provider vs. OMIG)
15 Integrated Approach Sentinel Effect = Improved Provider Billing 15 In summary, what we’re learning is that regardless of what program is catching an overpayment—TPL or Program Integrity, the goal is the same—to identify the overpayment, recover the dollars, identify the root cause, and then work with providers to ensure the overpayment doesn’t happen again.This new integrated approach is a comprehensive “payment recapture” program- -integrating individual TPL and PI programs into tiers – one program feeding into the other. We expect to see more recoveries, a reduction in future overpayments, and minimal provider abrasion.Sentinel Effect = Improved Provider Billing1515
16 OMIG/HMS Provider Portal Question:How are we going to work with the providers to help consolidate and streamline review distribution, reconciliation and recovery processing?Answer:OMIG/HMS Provider Portal16
17 Overview of the Provider Portal The Provider Portal is a web-based application that will allow providers a single point of entry for multiple OMIG reviewsThe provider portal is designed to accommodate multiple functionalitiesThird Party ReviewsPayment Integrity ReviewsProvider Self-DisclosuresMedicaid Credit Balance Reporting17
18 Accessing The Provider Portal Web-based with 128-bit security encryptionLogin for existing users and requesting a user account
19 New User RegistrationSelect Registration Type to pull up the appropriate registration formOnce the registration form has been submitted the new user will contacted by HMS to verify information
20 First Time Access Enter a new personalized password and confirm Enter the Current Password given to the provider by HMS during the registration processSelect security questions and answersClick OK
22 Third Party ReviewsEach Third Party Review is assigned a “cycle number”.“Cycle Search” allows the user to search for a specific review.Once you have selected the appropriate Third Party Review click to open
23 Third Party Reviews (cont) “Recipient Search” function allows the user to pull up all the claims that appeared on Third Party Reviews that belong to a specific patientClick to view claim detail
24 Third Party Reviews (cont) “Claim Search” function allows the user to pull up a specific claim that appeared on a Third Party ReviewClick to view claim detail
25 Responding to Third Party Reviews (cont) Information identifying cycle number, recipient, and third party coverageClaim InformationClick on the down arrow of “Provider Action/Reasons” to select the appropriate Action/Reasons codeClick “Ok” to save the Action/Reasons code and Provider Comments or click “Cancel” to discard changes and exit.Enter comments regarding the claim in the “Provider Comments” box
26 Payment Integrity Reviews Types of Payment Integrity ReviewsAutomated Reviews (e-Reviews)Consists of overpayments that can identified with extremely high accuracyProvider will be given 30 days to review findingsComplex ReviewsPotential overpayments where additional information is required to make a clear determinationProviders required to submit documentation to HMSHMS reviews the documentation and makes a determinationReviews will be sent to providers in a similar fashion as TPRTarget overpayments through data miningUpload targets to the Portal and notify providersProviders given clear instructions on how to satisfy each type of review
27 Self-DisclosuresUpon logging into the provider, users with appropriate will see the Self-Disclosure application listed on their home page.Click “Select” to access the application.
28 Self-Disclosures – Input Enter basic claim information needed to identify the claimEnter recipient’s informationEnter primary payor and payment information (if applicable)Enter refund amount and reason(s) for overpaymentClick “Submit” to submit the report to the “Supervisor” for final reviewAs refunds are entered and saved, they appear at the bottom of the screen
29 Self-Disclosures – Search Each user is allowed to query for refunds they entered and/or submitted.Users with “Supervisor” access will be able to query all refund entries for the given provider/facility.Query options. Enter the search criteria and click “Search”Search results are returned at the bottom of the pageClick “Details” to view full information on fileClick “Export” to export search results to an Excel spreadsheet
30 Self-Disclosures – Attestation Only the users with “Supervisor” access will be able to formally submit self-disclosures to OMIG-HMS. When submitting the final report, the “Supervisor” will be asked to attest to the information being submitted.
31 Medicaid Credit Balance Reporting Batch ReportingWill give providers the ability to upload completed worksheets with proper attestation, eliminating claim by claim data entry and reportingSupply a report template for providers to useMay require providers who chose to use batch reporting to under-go acceptance testing to verify correct formatting, accuracy of data, etc.Will mirror OMIG initiative to prompt self-disclosures
32 What to Watch for in 2011 Third Party Reviews Self-Disclosures Outreach underway to re-register providers to the OMIG-HMS PortalAnticipate uploading the first Review to the portal around March 21thSelf-DisclosuresDevelopment completedCurrently in the User Acceptance Testing (UAT) PhaseLooking for initial rollout to a small group of hospitals around April 25thWill seek feedback from the early adoptersCredit Balance ReportingCurrently in the design phaseAnticipating 3 month development and testingPayment Integrity ReviewsAnticipating 6 month development and testing
33 Timeline March 21, 2011 Third Party Reviews April 25, Self-DisclosuresJuly 1, Credit Balance ReportingOctober 1, Payment Integrity Reviews