Presentation on theme: "Medicaid Integrity Program … and other issues. The Medicaid Integrity Program Managed by CMS – not OIG ▫The Medicaid Integrity Group ▫David Frank, Director."— Presentation transcript:
The Medicaid Integrity Program Managed by CMS – not OIG ▫The Medicaid Integrity Group ▫David Frank, Director – former prosecutor Support not supplant state efforts – however, is expected to put a lot of pressure on states to perform Three divisions: ▫Medicaid Integrity Contracting: procurement and oversight of contractors ▫Fraud, Research and Detection: data-mining ▫Field Operations: offices in Chicago and 4 other states Special support to states
The Medicaid Integrity Program Three sets of contractors form based of program ▫Review MIC (Medicaid Integrity Contractors) – data mining ▫Audit MICs – field and desk audits – work with DOJ and OIG to make sure not duplicating or interfering Not contingency based contracts FFS claims and then cost reports; next managed care audits Identify but do not collect overpayments Do NOT identify underpayments – SEE HANDOUT ▫Education MICs: state and providers; Medicaid Institute for states run conjointly by the DOJ and CMS
The Medicaid Integrity Program Issues: ▫Contractors must learn on their own ▫Most audits will be desk audits Requests will come on the contractors letterhead – may end up with a CMS cover letter but not yet – WATCH for these requests In some cases identifying consumer only by Medicaid # ▫No limits on numbers of records that can be requested – they will not pay for copies ▫Illinois has a very short window for appeals ▫They will not be posting audits
New Federal Compliance Issues New York OMIG: work plan, required compliance programs – setting new benchmarks Quality of Care: ▫Medical Services: off-label usage; under 14; drug- seeking parents; cocktails, etc. ▫Board of Directors ▫Quality and Compliance and Risk Management and UR – no silos IMD: not settled; Georgia advice remains best but not necessarily workable Family-based interventions – engagement and outcomes
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