Presentation on theme: "Medicaid Integrity Contractors & Medicaid RACs Are You Prepared?"— Presentation transcript:
1Medicaid Integrity Contractors & Medicaid RACs Are You Prepared? WV HFMA Spring Revenue Cycle MeetingMedicaid Integrity Contractors & Medicaid RACs Are You Prepared?M. Jill Newberry, CPA, CPCSenior ManagerArnett Foster Toothman, P.L.L.C.
2Medicaid Integrity Program (MIP) In February 2006, the Deficit Reduction Act (DRA) of 2005 was signed into law and created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act (the Act). The MIP is the first comprehensive Federal strategy to prevent and reduce provider fraud, waste, and abuse in the $300 billion per year Medicaid program.Three – Year Rollout (Ordered by DRA ’05) Underway-- CMS Region V/VII (OH), Region III/IV (WV, VA, KY) audits scheduledto begin November 2009
3Medicaid Integrity Program (MIP) Not RAC: Rules, Players, Look-Back & Appeals DifferMIG’s – Medicaid Integrity Group – established by CMS in July 2006 to implement MIPMICs are Medicaid Integrity ContractorsMIC’s are paid contract fee, no contingency feesFocus on overpayments, no underpaymentsNo limit to record requests, no copying costsWorks in concert with State Medicaid Agencies and State Law EnforcementLook-back period mirrors state standardsCMS has two broad responsibilities under the Medicaid Integrity Program:To hire contractors to review Medicaid provider activities, audit claims, identify overpayments, and educate providers and others on Medicaid program integrity issuesTo provide effective support and assistance to States in their efforts to combat Medicaid provider fraud and abuse
4Medicaid Integrity Program (MIP) Involves Three Medicaid Integrity ContractorsReview, Audit & EducationAnnual Report to Congress RequiredReview MIC Works with CMS & Audit MICsAnalyzes Paid Claims Data, No pre-pay reviewsNo direct provider contact
5Review MICs Review Contractors Identifies “Aberrant” Claims, High-risk area and Potential VulnerabilitiesCMS: “Data driven approach ensures focused efforts”States can also recommend targetsRecommends leads & Provider targets to CMS and Audit MICsWorks with States & Feds to avoid duplicate audits
6Review MICs Who are the Review Medicaid Integrity Contractors? -- AdvanceMed (OH)-- Thomson Reuters (KY, VA, WV)
7Audit MICs Audit MICs Conducts Post-pay Audits of Medicaid Providers FAFAS Standards (“yellow book”)Audits performed by “appropriate & qualified” professionals: physician medical directors & RN reviewersCould involve medical record, bill data and other (?) provider recordsIdentifies OverpaymentsCan extrapolate sample reviewsWorks with CMS MIG & state Medicaid offices to finalize resultsState Medicaid agencies that normally collect payments will recover these payments as wellAudit MIC reports can be shared with Federal or State Law Enforcement Agencies
8Audit MICsAudit MICsEffective 10/26/09 - Health Integrity LLC (formerly Booz Allen Hamilton)– (KY, VA, OH & WV)
9Education MICs Education MICs Works with CMS & Other MICs to Prevent Future Medicaid Fraud, Waste & AbuseInteracts with all Medicaid StakeholdersProvidersMedicaid AgenciesMedicare FI/MACState & Federal Law Enforcement/State AuditorDevelops Training Materials, Awareness Campaigns & Conducts Provider Education
10Education MICs Education MICs Information experts Strategic Health Solutions confirmed for WV
11NY State Inspector General – Jim Sheehan Comments NY State IG Jim Sheehan provided some areas that providers cananticipate being audited by MICs:Dead or alive – was patient alive at date service was rendered?IP at time of ambulatory service – IP’s at a hospital at the time home health care or ambulance tripsHysterectomy on malesDebridement requiring actual cuttingHeart failure and shock – ambulatory surgery with no complication to justify the IP stayObservation beds – popular because Medicaid rules differ by state and differ from Medicare in most statesHiring excluded individuals – lack of thorough screening
12Office of the Medicaid Inspector General – NY Free Stuff Website –Mandatory Compliance Program – hospitals, managed care, all providers over $500,000/yearOver 1300 provider audit reports detailing findings in specific industry66 Page work plan issued 4/20/09 – shared with other states, CMS, OIG – new one due out this month!Listserv – put your name in, get updatesUpdates on MIC, IPRO & Thomson ReutersNY Excluded Provider List.
13How Does MIP Work?1.CMS & Review MIC Identify Potential Projects/Targets2. CMS & Review MIC Outline Projects/Targets with State Medicaid, FI/MAC & StateAgencies to avoid duplication3. Review MICs analyze Medicaid claims data to identify providers with potentialoverpayments. From the resulting lists of providers, CMS selects audit targets toassign to Audit MICs.4. CMS forwards approved projects/targets to Audit MIC5. Audit MIC Notifies Provider ContactAt least two-week notice with list of accounts; extensions granted upon request for large projects – Expect no more than 45 daysPatient identifying data is limited (Medicaid SSI # & DOS)Audits will most often be done off-site – records required to be readied and available accordingly – no copying costsAudit MIC will outline details in “entrance conference”
14How Does MIP Work? 6. Audit MIC Performs Audit According to GAGAS 7. Audit MIC Holds Exit ConferenceProvider has chance to provide additional information8. Audit MIC Shares Draft Report with Provider, CMS & State)Provider & State have chance to review and comment9. CMS Finalizes Report, Settles any differences and Determines Amount of Overpayment10. CMS Issues Final Report to State and triggers 60 (calendar) day repayment timeline11.State Issues Final Report to ProviderState handles appeals according to its rulesState Recoups Overpayments according to its process
15WV – BMS Office of Quality Program Integrity Director of Program Integrity – Tammy Hypes“MIP is still a work in progress”Spoke with Tammy Hypes 3/15 and she stated that the MIC is not their focus at the moment.Other states have kicked off their MIC programsThey are currently working with Health Integrity on behind the scenes work such as getting their data aligned to prepare to perform data mining.
16MIC Audits Common areas under scrutiny: One day stays Provider eligibilityBilling for services not providedReimbursements for unapproved drugsDuplicate billingProviding services not medically necessaryProviding services that may compromise the quality of careExcessive payments and “upcoding” for higher reimbursement of billed proceduresBilling for services provided by unlicensed or untrained personnelPayments for unapproved transportation servicesMedicaid eligibility in multiple statesContingency fee payments to consultants and service providersProviding false certifications in the claims process
17OIG Report – Few Overpayments Collected As of Feb 2012 Review MICs identify 113,378 providers$282 Million in Potential OverpaymentsCMS selects 244 providers as audit targets$39.8 Million in Potential OverpaymentsCMS assigns 161 providers as audit targets$33.5 Million in Potential Overpayments25 provider audits completed$285,629 in Actual Overpayments
19Medicaid RACThe Affordable Care Act (ACA) requires Medicaid agencies to contract with Recovery Audit Contractors (RACs) to identify and recover overpayments and to identify underpayments.States must also develop processes for entities to appeal RAC determinations, and coordinate RAC efforts with other Federal and state law enforcement agencies.Most states have begun to develop comprehensive Medicaid RAC solutions to meet ACA requirements.
20Medicaid RAC West Virginia State Plan Amendment (SPA) Submitted 1/4/2011SPA Approved 3/28/2011The state is not seeking any exemptions from RAC audit scopeA RAC RFP was issued in May 2012, with a response due date in July Claim types to be audited under the RFP scope are limited to medical, dental, and DME.In September 2012, the state awarded the RAC contract covering medical, dental, and DME claims to HMSA separate RAC RFP focusing exclusively on pharmacy claims was issued June 2012, and had a proposal due date of August 9; this pharmacy-only RAC RFP was subsequently canceled and will be re-bid
21Medicaid RAC Ohio SPA Submitted 12/22/2010 SPA Approved 3/22/2011 The state is not seeking any exemptions from RAC audit scopeA RAC RFP was issued January 2011 and closed March 2011; RAC scope includes overpayment and underpayment identification, and quality and control of Medicaid services provided.The RAC contract was awarded to CGI (May 2011)
22Medicaid RACTen of the most important elements of the rule that states, managed care organizations (MCOs), and other stakeholders should be aware of are:1. The deadline for states to implement their Medicaid RACs is now January 12, The final rules are not effective until that time.2. States may exclude MCOs from review by Medicaid RACs, but are not required to do so.3. States must set limits on the number and frequency of medical records to be reviewed by the Medicaid RACs subject to requests for exceptions made by the RACs.4. States must notify providers of underpayments that are identified by the Medicaid RACs, and they must adequately incentivize RACs to detect underpayments. Medicare RAC underpayments, which made up 18% of corrections last year, will be used as a benchmark for Medicaid RACs. CMS will also look at the trends among the states.5. CMS will allow states to establish “regional” Medicaid RACs.
23Medicaid RAC6. Medicaid RACs must notify providers of overpayment findings within 60 calendar days.7. CMS will be developing performance metrics with states to determine the accuracy of RAC reviews.8. CMS will allow states to determine at what stage of the audit process RACs will receive the contingency fee. States should specify in their RAC contracts the time frame in which the state expects the Medicaid RAC to return the contingency fee in cases in which a determination is reversed at any level of the appeals process.9. If a state is interested in “bundling” its Medicaid RAC procurement with other services (for example: third party liability) that are currently being performed by an existing contractor, the state must execute a separate task order outlining the requirements of RAC program for the existing contractor.10. Medicaid RACs are not required to collect overpayments, only to identify them. States have the flexibility to coordinate the collection of overpayments.
24Medicaid RAC Per HMS website: We conduct face-to-face meetings and conference calls with hospitals and provider associations, and individual providers. We work with multiple contacts at your facility to make sure that everyone has a common understanding of the process and objectives.A 24/7 state-of-the-art web-based portal to help you navigate the overpayment identification and recovery process — without the burden of paperA full-time Provider Services team to guide you through the audit process. Our team is focused exclusively on responding to your inquiries, and has the experience required to promptly and accurately respond to your questions regarding the review and recovery process.Regular updates on findings. We regularly participate in state hospital and provider association meetings and publish information about trends and issues identified on our website. We also publish quarterly newsletters and conduct webinars to keep you up to date.A highly skilled Clinical Review team. Registered nurses, certified coding professionals, and physicians experienced in the review of medical records work together to review claims and make fair determinations based on your state’s policy and regulations.Guidance on how to correct overpayment errors in the future. Provider education is important to us. Our determination letters include detailed clinical rationales so you’re 100% clear on why a claim is denied, and how to prevent the overpayment on future claims.
25Medicaid RACFAQ: Are state’s required to give providers advance notice about the audit areas on which the Medicaid RAC’s might focus similar to when the Medicare RAC first started?Answer: CMS is not requiring states to publicize the audit areas on which their Medicaid RACs will focus. States have a certain degree of flexibility to design their Medicaid RAC programs to meet their specific needs. However, we believe that states should promote transparency in their RAC programs. Encouraging RACs to give advance notice to providers of audit areas on preparation of review is an example of how states can facilitate transparency.
26Medicaid RACThe final rule at 42 CFR § (e) provides that a state must set limits on the numberand frequency of records to be reviewed by it’s RAC. The state has the flexibility to set the limits.The final rule at 42 CFR § (f) specifies that a Medicaid RAC must not review claims that are more than 3 years from the date the claim was filed unless it receives approval from the stateMedicaid RACs operate at the direction of the State. States have the discretion to determinewhat areas of their Medicaid program to target based on the program integrity landscape in the State.States should provide the Medicaid RACs with the most accurate data available in order to ensure the most accurate audit results.CMS expects States to work with their Medicaid RACs to identify vulnerabilities within each State’s Medicaid Program.
27Medicaid RAC Molina will present general workshops during April, 2013. Various contractors will be at the meetings to present on various topics includingMedicaid RAC,Appeal and Reconsideration processesPERM,Re-enrollmentInvites for these workshops have not gone out yet as of Friday March 15. Check your inbox and/or find it in your organization and sign up!All services covered by Medicaid are available for the RAC to review.WV – won’t put any information out on any websites until they are sure they will focus on it.New False Claims Review Criteria for States – March 15, 2013:https://oig.hhs.gov/fraud/docs/falseclaimsact/guidelines-sfca.pdf
28Medicaid RAC – Locations for Workshops LOCATION DATE TIME LOCATION DATE TIME Martinsburg – April 15, :00 am – 1:00 pm Holiday Inn Morgantown – April 16, :00 am – 1:00 pm Waterfront Hotel Wheeling – April 17, :00 am – 1:00 pm Oglebay Park Pine Room Flatwoods – April 22, :00 am – 1:00 pm Days Inn HotelHuntington – April 23, :00 am – 1:00 pm Big Sandy Arena Beckley – April 24, :00 am – 1:00 pm Tamarack Charleston– April 25, :00 am – 1:00 pm Marriott Town Center – Pavilion
29Medicaid RAC Areas most likely to be targeted: Medical necessity claimsDME claimsUnits of therapy claimsCardiac claimsOther high dollar claimsDrug units
30Medicaid RAC What can you do now? Stay on top of the general Medicaid billing rules, not just RACs and appealsConduct real-time, open chart audits to ensure accurate and compliant documentationIt may be beneficial for a provider to have someone on the front end at registration that is qualifying and screening potential Medicaid recipientsMeasurement of accuracy and exchange of information are important for long-term success and accountabilityEnsure processes are in place for real time management of the bed placement and appropriate documentation are crucial to getting the rules right on the front endThere must be some type of structure that brings together the finance, clinical, and utilization review functionsAll roles related to billing compliance should serve on the billing/compliance RAC committee or any other type of centralized committee.Basically this will be utilizing current processes for Medicare RAC but be sure to have a process in place to keep the requests and responses separate.