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Medicaid Program Changes: Addressing Concerns for the Clinical Laboratory A Webinar Program Presented by Christopher Young, CHC

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Presentation on theme: "Medicaid Program Changes: Addressing Concerns for the Clinical Laboratory A Webinar Program Presented by Christopher Young, CHC"— Presentation transcript:

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2 Medicaid Program Changes: Addressing Concerns for the Clinical Laboratory A Webinar Program Presented by Christopher Young, CHC

3 Objectives Explain the fraud and abuse provisions contained in the Affordable Care Act (ACA) that pertain to the Medicaid and Children’s Health Insurance program (CHIP) Understand what the Medicaid Integrity Program is and how it affects laboratories and other providers Review October 2010 implementation of the NCCI and MUE edits in the Medicaid programs Formulate a plan to monitor and prepare for these changes

4 Expanded Medicaid and CHIP Population ACA will provide government funded health care to the largest group of people in history Many, if not all, of these people will be paid under programs similar to existing Medicare and Medicaid programs and payment policies The ACA will accomplish its goal of providing coverage for today’s uninsured in several ways, among them are: –Expand Medicaid to 133% of the poverty level in 2014 –Extends programs for CHIP and Medicaid children until 2019

5 The ACA and the MIP One of the chief concerns of the Federal Government is what it considers rampant fraud and abuse of its programs by providers, contracted payers and the beneficiaries themselves For that reason, the ACA included several provisions designed to fight fraud and abuse and reduce claims paying errors in its programs It also bolsters existing fraud fighting tools by adding more funding, hiring more people and increasing the severity of penalties Medicaid Integrity Program (MIP) is one of the more important programs established to fight fraud and abuse in Medicaid

6 Medicaid Integrity Program (MIP) The Deficit Reduction Act of 2005 (DRA) established the MIP in Section 1936 of the Social Security Act Initial funding - $560M over 5 Years –$255m for Medicaid Integrity Program –$180m to expand the National Medi-Medi program that compares claims data between Medicare and Medicaid Staffing FTEs for CMS specifically to fight Medicaid and CHIP fraud and abuse ACA extends and supplements funding of health care fraud fighting efforts including the MIP 6

7 Comprehensive Medicaid Reports Comprehensive Medicaid Integrity Plan (CMIP) reports on the are required each year and include plan for the next five years of the MIP The report for 2009 – 2013 provides an over view of planned activities and lists completed activities As of December 2009, according to the report, all staffing is in place There was an excess of $11 million from 2008 fiscal year carried forward to 2009 to add to the $75 million available from the original funding There is an excess of $5 million left over from 2009 for use in 2010 in addition to the $75 million for

8 Comprehensive Medicaid Reports 2009 saw the finishing touches on preparation for auditing activities Loaded claims information into the Medicaid Integrity Group (MIG) “data engine” –National data base of of Medicaid claims –Will include data models to predict suspect provider behavior by provider type Combined claims data elements for the Medicaid Statistical Information System (MSIS) to collaborated better with other agencies for overpayment detection and analysis 8

9 Medicaid Integrity Program Contractors Medicaid Integrity Contractors ( MICs) –2009 was the first full year of audits under the MIP 600 audits underway in close to half of all states Identified an estimated $8.5 million in overpayment Three kinds of contractors –Review MIC – reviews provider claims and develops “target” lists –Audit MIC – audits provider claims and identifies overpayments –Educate MIC – educates providers on payment integrity & quality of care 9

10 MIP/CMS Regions Regions I/II - CT, MA, ME, NH, NJ, NY, PR, RI, VT & USVI Regions III/IV - AL, DC, DE, FL, GA, KY, MD, MS, NC, PA, SC, TN, VA & WV Regions V/VII - IA, IL, IN, KS, MI, MN, MO, NE, OH & WI Regions VI/VIII - AR, CO, LA, MT, ND, NM, OK, SD, TX, UT & WY Regions IX/X - AK, Am. Samoa, AZ, CA, Guam, HI, ID, No. Marianna Isl, NV, OR & WA 10

11 Review MICs The five Review MICs are: –AdvanceMed Corporation; –ACS Healthcare Analytics, Inc.; –Thomson Reuters; –Safeguard Services, LLC; and –IMS Government Solutions Analyze Medicaid claims data to identify high-risk areas and potential vulnerabilities Provide leads to the Audit MICs Use data-driven approach to ensure focus on providers with truly aberrant billing practices 11

12 Audit MICs The five Audit MICs are: – Booz Allen Hamilton; – Fox Systems, Inc.; – Island Peer Review Organization (IPRO); – Health Management Systems (HMS); and – Health Integrity, LLC. Conduct post payment audits of all kinds of providers that include a combination of desk and field audits Where appropriate, identify overpayments to these providers 12

13 Education MICs There are two education MICs –Information Experts –Strategic Health Solutions Work with Medicaid programs to provide education and training for staff Develop training material based on findings from audit and review MICs to raise awareness and provide training for providers Highlight the value of education in preventing fraud, waste and abuse 13

14 Medicaid Integrity Group (MIG) Implemented and now operates the MIP Conducts audits and reviews of State program integrity efforts and individual audits and reviews –18 were done in 2009 Also responded to state requests for support Is responsible for and continues to build on the MIG data engine mentioned previously Through the use of the data engine, analysis of data that used to take days, now takes minutes Also coordinates investigations of cross border, regional and national issues 14

15 Primary Focus-Audit MICs MICs work for CMS, not for the State program Audits will be conducted according to the Generally Accepted Government Auditing Standards Audits are focused on billing for covered services, that were actually provided and properly documented CMS is responsible to insure that MIC audits do not duplicate other State audits nor interfere with potential law enforcement investigations 15

16 MIC Audits Once audit is assigned, providers receive a notification letter and a listing of records that will be audited –Generally, two weeks in advance of the audit –More time may be given in some cases Records may be copied and sent for a desk audit, or, must be available for the auditor when they arrive on-site for a field audit 16

17 MIC Audits MIC will contact provider to schedule an entrance conference Most audits will be desk audits where records are copied and sent and entrance conference is by telephone Audits can be large and include large numbers of records –MICs are not bound by limits on record requests or on “look back” timeframes –Generally, time for record production will be the same as the Medicaid contractor usually requires 17

18 MIC Audits After audit is completed, MIC will schedule a exit conference –Provide summary of findings –Provides opportunity to comment and/or provide additional information If there is a potential overpayment, MIC prepares draft audit report Draft report is approved by CMS before going to the State to review 18

19 MIC Audits After State review, report is shared with provider for review and comment –Report may be revised in some cases based on evidence After all parties agree to the results, audit is finalized –CMS has final say in any disputes over interpretation of laws or regulations etc. Final report is sent to the State by CMS 19

20 MIC Audits State has 60 days to to repay the Federal government its share of the overpayment whether it collects from providers or not State issues final report to provider and initiates its payment recovery process Provider may exercise its appeal rights at this point in the process Audit MIC will be available to support the State efforts in dealing with appeals etc. 20

21 Mandatory Use of NCCI Letter dated Sept 1, 2010 from CMS to State Medicaid Directors –First in a “series” meant to provide guidance on the mandatory implementation of the NCCI as required by the ACA –Effective for Medicaid claims filed on or after October 1, 2010 –NCCI includes MUEs Same “confidentiality of specific edits” applies to Medicaid as Medicare

22 State Flexibility in Incorporating Edits CMS has withheld some edits because of concern with “compatibility” for some state programs CMS understands that states are in different stages in implementing the edits but it will still hold providers accountable beginning October 1, 2010 State edits will be updated as are the Medicare edits, once a quarter States may request deactivation of some edits if there are conflicts with state laws, regulations, administrative codes or rules, payment policies or operational readiness States also can incorporate MCDNCCI edits that go beyond the Medicare edits

23 Common Errors by States Error 1: The edits are applicable for the same service by the same provider, to the same beneficiary on the same date of service and not to any other circumstance –Other circumstances should not be attributed to NCCI edits Error 2: NCCI edits with a modifier indicator of “1” must allow use of NCCI associated modifiers to bypass the edit Error 3: MUE edits are claim line edits, not edits for an entire claim –Each claim line must be adjudicated separately

24 Other Medicaid NCCI Information CMS will make several documents available like an FAQ, an article about the use of the 59 modifier, a separate policy manual for Medicaid NCCI edits and other items Providers may appeal NCCI edits There will be some lag time during the last quarter of 2010 but effective January 1, 2011, the Medicaid NCCI edits will be delivered to the states by CMS 15 days prior to the start of the new quarter just like Medicare States that use Commercial Off-the-Shelf (COTS) software for implementing NCCI edits must have confidentiality agreements in place that comply with Federal contracting requirements

25 Daniel Levinson Testimony On September 22 nd, Daniel Levinson, the OIG for Health and Human Services testified before Congress on the subject “Cutting Waste, Fraud, and Abuse in Medicare and Medicaid” –Serious issue that requires concentrated and sustained effort –Discusses “innovative uses of data are central to program integrity efforts” –ACA provides significant enhancements in the effectiveness of the fight

26 Daniel Levinson Testimony Five principle strategies to combat fraud and abuse 1.Scrutinize enrollment in Federal programs both before enrolling them and at reenrollment 2.Establish payment methodologies the change with changes in the marketplace 3.Assist providers in adopting compliance programs that lead to practices that promote compliance 4.Vigilantly monitor and audit its programs for evidence of fraud and abuse 5.Respond swiftly to violators and impose sufficient punishment to deter others

27 Plan for Medicaid Changes Make certain you know the rules for the Medicaid program in your state –Visit and book mark your state Medicaid webpage Make certain you know what MIC contractors are active in your state –Find out if they have a website and visit it Set up an internal system to make certain that notices and requests for records are promptly handled and/or routed to the appropriate person Have a process in place to review and evaluate requests for records or demand letter for refunds –If there are questions make certain they are asked in a timely manner by having phone contacts ready before hand Make copies of everything sent to an auditing entity Do your own internal review of any requested records

28 Plan for Medicaid Changes Make certain you are aware of all Medicaid policies and procedures If you are audited, be prepared to review the contractor’s results to make certain they are correct –Don’t just accept the contractor’s interpretation If you have questions or disagree with the audit results, contact the auditing entity as soon as possible –Support your case with documentation Document and archive everything in such a manner that it is retrievable in the future Provide training and education of all employees that may be affected by Medicaid audits so they are aware of the risks and hazards

29 Resources and Information CMS “Medicaid page” –http://www.cms.gov/home/medicaid.asp CMS letters to Medicaid Director –https://www.cms.gov/SMDL/SMD/ (NOTE: sort list in descending order to find letter quickly) Levinson Testimony –www.oig.hhs.gov/testimony/docs/2010/testimony_levin son_ pdf To find your state Medicaid program website conduct a search with your state name and the word “Medicaid” –E.g. Arizona Medicaid

30 Objectives Explain the fraud and abuse provisions contained in the Affordable Care Act (ACA) that pertain to the Medicaid and Children’s Health Insurance program (CHIP) Understand what the Medicaid Integrity Program is and how it affects laboratories and other providers Review October 2010 implementation of the NCCI and MUE edits in the Medicaid programs Formulate a plan to monitor and prepare for these changes

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