1. A Peek at ZPIC/PSC Benefit Integrity Unit Complaint & Referral Process Amy Miller-Bowman PSC Midwest Integrity Center

2. *Other territories of Zone 1 include American Samoa, Northern Marianas Islands and Guam **Cahaba received the award for Zone 3, but it is currently on a stop-work order due to contract protest Zone 1: SGS* Zone Program Integrity Contractors (ZPICs) 2

3. CMS PIM Requirements Program Integrity Manual (PIM) requires all investigations be: Unique Tailored to specific circumstances PSC and ZPIC Benefit Integrity (BI) Units: Must use variety of techniques, both proactive and reactive, to address any potentially fraudulent billing practices 3

4. CMS PIM Requirements ZPIC BI units Investigations and cases with greatest program impact/and or urgency must be given highest priority. Allegations or cases having greatest program impact involve: Patient abuse or harm Multi-state fraud High-dollar amounts of potential overpayment Likelihood for increase in amount of fraud or enlargement of pattern 4

5. Complaint Screening After receipt, complaint is screened Screening process includes a query for past complaints (both open and closed) regarding the provider Current provider information includes: National Provider Identification (NPI) number Provider address Chain information After screening, complaint is assigned to an investigator. 5

6. Review small sample of claims recently submitted May need to request medical documentation or other evidence that would validate or cast doubt on claim validity Investigation Steps 6

7. Conduct telephone interviews of small number of beneficiaries to determine if: If other false claims appear to exist OR If this was a one-time occurrence Investigation Steps 7

8. Look for past PSC, ZPIC, or MR unit contacts concerning comparable violations Check provider correspondence files for: Educational/warning letters Contact reports that relate to similar complaints Review complaint file Discuss suspicions with MR and audit staff, as appropriate Investigation Steps 8

9. Perform data analysis Review telephone calls or written questionnaires to physicians, confirming need for home health services or DME Perform random validation checks of physician licensure Review original CMNs 9

10. Investigation Steps Perform analysis of procedures and items: High frequency/high cost High frequency/low cost Low frequency/low cost Low frequency/high cost 10

11. Investigation Steps Perform analysis of local patterns/trends of practice/billing against national and regional trends: Begin with top 30 national procedures for focused MR and other kinds of analysis that help identify cases of fraudulent billings Initiate other analysis enhancements to authenticate proper payments Perform compilation of documentation: Medical records Cost reports 11

12. Investigation Steps Using internal data, PSC and ZPIC BI units may determine: T ype of provider involved in allegation Perpetrator (if an employee of provider) Type of services involved in allegation 12

13. Investigation Steps Examples of areas to be researched: Places of service Claims activity (including assigned and non-assigned payment data in the area of the fraud complaint) Existence of statistical reports generated for the Provider Audit List (PAL) or other MR reports, to establish if this provider's practice is exceeding the norms established by their peer group (review the provider practice profile) 13

14. Investigation Steps If any documentation is available on prior complaints, obtain: Appropriate Form CMS-1490s and/or 1500s UB-92s Electronic claims, and/or attachments Review all available material Decide if it is reasonable to spend additional investigative resources 14

15. Discussion with OIG/OI If pattern appears, discuss with OIG/OI at onset of investigation At the end of all investigations, discuss investigation facts with OIG/OI Obtain OIG’s recommendation on whether or not investigation should be further developed for possible case referral to OIG/OI 15

16. Final Steps If investigations do not result in a case, the PSC and the ZPIC BI Units take all appropriate action: To prevent any further payment of inappropriate claims To recover any overpayments that may have been made 16

17. And the Security Door Closes… Due to contractual obligations and legal requirements, sometimes information cannot flow both ways. As ZPIC/PSC contractors, we empathize how frustrating this can be to the SMP and the beneficiary. 17

18. Alice’s Story Alice lives in Iowa and is 87 years old. Alice has been in hospice care for 8 months. Alice’s hospice company recently called Alice’s daughter to report more than 1200 Oxycotin pills were missing. Hospice company believes a hospice nurse has been stealing the medication. 18

19. Alice’s Story Alice’s daughter also had concerns about Alice’s recent recertification for hospice from the physician: Face-to-face visit No vitals taken Lasted 5 minutes Alice’s daughter told the news about the missing medication and the hospice recertification to her own daughter, who works for a PSC. 19

20. Alice’s Story Alice’s granddaughter documented and reported all information to the ZPIC contractor. ZPIC contractor informed the MFCU. 20

21. And the Security Door Closes… As a contractor, Alice’s granddaughter understands she has no guarantee she will ever learn results from Alice’s reported case. 21

22. Thank you!