SMP Casework Trends, Tips, and Tricks

SMP Casework Trends, Tips, and Tricks
Barbara McCoy and Sara Vogler ACL

Agenda Anatomy of a Case SIRS Data Summary Questions and Answers

8/22/2018 Anatomy of a Case Step 1: Identify a case to refer to the OIG Hotline via ACL Step 2: Develop the case Step 3: Submit the case in SIRS Step 4: ACL follows up Step 5: The OIG follows up Step 6: Close the case Please note that the steps may not follow this exact sequence all the time. Specifically, you may enter as much as you can about the case in SIRS (step 3) before you finish developing the case, then develop the case some more and enter more in SIRS. mccoy in Ballroom on 8.22 at 1100 no repeat

Step 1: Identify an SMP Referral to the OIG Hotline via ACL
SMP Casework Trends, Tips, and Tricks 8/22/2018 Step 1: Identify an SMP Referral to the OIG Hotline via ACL Initial conversation with the beneficiary Identify the conversation as an SMP complex interaction See the SMP Counselor Training resources. Identify the SMP complex interaction as a referral to the OIG Hotline See the SMP Complex Interactions Training resources. mccoy in Ballroom on 8.22 at 1100 no repeat

Is it a Complex Interaction? Use the SMP Counselor Training Manual, Appendix A: Types of SMP Questions Flow Chart SMP Casework Trends, Tips, and Tricks 8/22/2018 1) Is the question related to the SMP mission? NO YES MAYBE This is not an SMP interaction. Send the person to the appropriate entity for help. See Appendix B. This is an SMP individual interaction. See below. If the question is too complex to be sure, send the person to someone at your SMP who handles complex interactions. Use the SMP Counselor Training Manual to help you determine if the conversation is an SMP complex interaction. Appendix A of the SMP Counselor Manual provides a flow chart that will help you to distinguish if a question is a basic interaction, complex interaction, or not an SMP question. This manual also provides information about how to handle basic interactions through SMP counseling, as well as where to send people for help with other questions that are not related to the SMP mission (see Appendix B: Contacts Outside of the SMP). 2) Can the question be resolved by providing education or information? YES. NO. This is a basic interaction. This is a complex interaction. mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 Is it a Referral to the OIG Hotline via ACL? Use the SMP Complex Interactions Training Manual, Appendix A Use the SMP Complex Interactions Training Manual to help you determine what type of case it is and what type of follow-up might be needed. The flow chart in Appendix A of the SMP Complex Interactions Training Manual shows where to send each type of referral. For example, referrals of compromised Medicare numbers are sent to the OIG Hotline via ACL, the FTC, and local law enforcement. MEDIC = Medicare Drug Integrity Contractor CMS RO DOI Liaison = CMS Regional Office Department of Insurance Liaison mccoy in Ballroom on 8.22 at 1100 no repeat

Step 2: Developing the Case
SMP Casework Trends, Tips, and Tricks 8/22/2018 Step 2: Developing the Case What makes a good referral? Tips on writing good case notes Examples of what to do and what not to do when writing case notes We will be providing some tips that may be beneficial as you develop the case. We will talk about what makes a good referral, tips on writing case notes, and we will provide some examples of case notes. mccoy in Ballroom on 8.22 at 1100 no repeat

What Makes a Good Referral?
SMP Casework Trends, Tips, and Tricks 8/22/2018 What Makes a Good Referral? Who? What? When? Where? How? Documents You as the first person to receive the complaint are who we consider as the “eyes and ears” of the investigator of the appropriate federal agency who receives the referral, and the best person to help the get the case off to the right start. As a complex interactions specialist, you need to obtain as much detail as possible in efforts to provide a good referral to ACL/SMP and the appropriate federal agency for review. When obtaining information from the complainant/beneficiary, we need to know- Who: contact information for beneficiary/complainant and subject. What: what is the issue? Compromised Medicare number? DME issue, etc When: when did the issue occur? Where: where did the issue occur? A phone call? Provider’s office? How: what happened? How did the issue take place? Was it a call? Was it a bill? Documents: Providing documents to substantiate the issue is extremely important because this will assist the investigator when he/she reviews the issue. mccoy in Ballroom on 8.22 at 1100 no repeat

What Makes a Good Referral, continued…
SMP Casework Trends, Tips, and Tricks 8/22/2018 What Makes a Good Referral, continued… Provide as much information as possible in the fields about the beneficiary, complainant, subject, and any other applicable fields in SIRS. Collect and upload documentation to substantiate the issue. Provide great case notes to describe the issue. Collect contact information and enter in SIRS. Currently, beneficiary and subject fields are not required in SIRS but are required for investigators. However, in some cases, we understand that you may not be able to obtain contact information such as a subject who called but does not provide name or number and/or it does not show up on caller ID. Documentation is extremely important to substantiate the issue. Examples of documentations are MSNs, billing statement, proof of payment, dialogue, etc. Case notes: should be concise and direct to the point of issue at hand. mccoy in Ballroom on 8.22 at 1100 no repeat

Case Notes: What to Do and NOT to Do
SMP Casework Trends, Tips, and Tricks 8/22/2018 Case Notes: What to Do and NOT to Do Instead… Enter contact information in the Beneficiary, Complainant, and Subject fields in SIRS. Don’t provide beneficiary, complainant, or subject contact information in the case notes. Instead… Provide the MSN! Upload MSNs and other documentation in SIRS. Don’t include detailed information from the MSN. Instead… Provide a concise summary to describe the case. Don’t be too wordy in the case notes. Here are some examples of what to do and what not to do when writing case notes. mccoy in Ballroom on 8.22 at 1100 no repeat

The MSN: A Picture’s Worth 1,000 Words
SMP Casework Trends, Tips, and Tricks 8/22/2018 The MSN: A Picture’s Worth 1,000 Words Instead of providing all of the details about the MSN in your case notes, provide the MSN! The beneficiary can provide a printed copy, an electronic version, or even a screenshot of their MSN, including the beneficiary name, provider name, service date(s), and amounts. Be cautious when receiving the MSN or screenshots of the MSN electronically from the beneficiary, since is not a secure way to send data. “Send” the MSN and other documentation to ACL securely by uploading it in SIRS. Instead of providing all of the details about the MSN in your case notes, provide the MSN! The MSN is more helpful than a description of it. We need to keep the case notes concise, partially to save time for those writing them and those reading them, and partially because of character limitations in the OIG’s system. The beneficiary can provide a printed copy, an electronic version, or even a screenshot of their MSN. The OIG will accept a screenshot of the beneficiary’s information on MyMedicare.gov as documentation as long as it is clear enough to read and includes: the beneficiary name, provider name, service date(s), and the amounts. An MSN with the beneficiary’s information blacked out so it could be ed is actually not acceptable documentation. The OIG needs to be able to see the beneficiary’s name and other pertinent details on the MSN. As usual, both the original amount and the reconciled amount (whether it’s a lowered amount or $0) will need to be documented. Be cautious when receiving the MSN or screenshots of the MSN electronically from the beneficiary, since is not a secure way to send data. Other, more secure options include sending encrypted s or faxing the MSNs. “Send” the MSN (or screenshot), and other documentation, to ACL securely by uploading it in SIRS. mccoy in Ballroom on 8.22 at 1100 no repeat

Case Notes: A Concise Summary
SMP Casework Trends, Tips, and Tricks 8/22/2018 Case Notes: A Concise Summary Case Notes Be concise! Briefly summarize the situation as the complainant described it to you. Be clear! Your case notes need to make sense to someone outside the agency. Be objective and factual! Do not enter subjective observations. Additional Details If you feel it’s useful to provide more details, type them in a separate document and upload the document in SIRS. This may include: Actions you take for the complainant and/or that the complainant took on their own behalf. Anything else that you think may be beneficial to ACL, CMS, or the OIG but doesn’t fit in the case notes. Case Notes Use the “Case Notes” field to describe your case. Be concise! For example, don’t write the case as “he said-she said”, don’t write it as a story/novel”, etc. Briefly summarize the situation as the complainant described it to you. This description is a crucial aspect of your case. Provide a well-written narrative summary that will grab the attention of investigators. Explain key facts about the complaint leading you to the suspicion of fraud or abuse. If an error is suspected, explain why. It’s also important for the case notes to be to the point, because I will copy your case notes from SIRS and paste them into the OIG Hotline’s online reporting system. Since I didn’t talk to the beneficiary, I don’t have enough information to edit the case notes to add information or make them more concise. Be clear! Your case notes need to make sense to someone outside the agency and to someone who wasn’t sitting with you when you met with the complainant. As you write your case notes, keep in mind that this is your time to explain the situation to ACL, the OIG, and/or CMS. Use complete sentences, since this will be read by others. Avoid using state- or SMP-specific acronyms. If you do need to use them, make sure you also explain what they mean. Be objective and factual! Do not enter subjective observations. Additional Details If you feel it’s useful to provide more details than what will fit in the case notes, type them in a separate document and upload the document in SIRS. I can then upload this document into the OIG system in addition to the case notes you provide. This may include: Actions you take for the complainant and/or that the complainant took on their own behalf. For example if you contacted another party on their behalf (i.e. Medicare, plan, doctor’s office) be sure to include the date, time and name of the person you talked to, what you talked to them about, and include any resolutions. Anything else that you think may be beneficial to ACL, CMS, or the OIG but doesn’t fit in the case notes. See the SIRS Complex Interactions Job Aid for case notes tips. mccoy in Ballroom on 8.22 at 1100 no repeat

Step 3: Submitting the Case in SIRS
SMP Casework Trends, Tips, and Tricks 8/22/2018 Step 3: Submitting the Case in SIRS All SMP cases involving Medicare fraud are sent to via SIRS See the SIRS Complex Interactions Job Aid After you have compiled all (or most) of the necessary information about the case, enter the case in SIRS and make the referral to the OIG Hotline via ACL in SIRS. In some cases, you will start entering the case sooner so that you can upload documentation, etc. In other cases, you will wait until you have missing information before you start entering the case. Use the SIRS Complex Interactions Job Aid to guide you through your data entry in SIRS. mccoy in Ballroom on 8.22 at 1100 no repeat

Submitting an OIG Referral in SIRS
SMP Casework Trends, Tips, and Tricks 8/22/2018 Submitting an OIG Referral in SIRS Enter the complex interaction in SIRS. Include all applicable data fields and detailed case notes. In the “SMP Action” section, select “referral” and “contact OIG,” plus any other boxes that apply. In the “Refer to OIG Hotline via ACL” field, select “Yes”. The referral is automatically sent to ACL through SIRS and a notification is automatically sent ACL. You do not need to ACL. If you ever do need to ACL or the Center about a case, only the case number. Do NOT provide any personal information in your s, not even the beneficiary’s name. ACL and the Center have access to look at your case with you in SIRS. mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 Key Data Entry Fields in SIRS a.k.a. “required fields that aren’t marked as required” Beneficiary contact information Permission to contact Subject information Complainant contact information (if not the beneficiary) SMP actions Case notes Refer to OIG Hotline via ACL = Yes SMP representative information Status of Interaction Date of Last Status Update R Although the fields listed here, such as beneficiary and subject, are not required in SIRS; it is beneficial for the SMP Team, OIG, and FTC to have as much information available to proceed with the case. We would like you to think of all of these fields as required whenever they apply to your case. Let’s take a look at each of these fields and where they appear in SIRS. mccoy in Ballroom on 8.22 at 1100 no repeat

TIP: Case Notes and Refer to OIG Hotline via ACL
SMP Casework Trends, Tips, and Tricks 8/22/2018 TIP: Case Notes and Refer to OIG Hotline via ACL OR “Not Yet”! Enter case notes here. You may want to type your case notes on a Word document, then summarize them and copy them here, since the field is so small in SIRS. If making a referral to OIG Hotline via ACL, the “refer to OIG Hotline via ACL” button must be selected as “Yes”. However, documentation cannot be uploaded from eFile. So, do not refer the case to the OIG in eFile if you have documentation to upload. Complete as much information as possible in eFile but select “No” for now. After saving the case in eFile, write down the case number and log into SIRS to upload the documentation, and then refer the case after you have finished all of your uploads and any additional updates. mccoy in Ballroom on 8.22 at 1100 no repeat

TIPS: Referrals to the OIG Hotline via ACL
SMP Casework Trends, Tips, and Tricks 8/22/2018 TIPS: Referrals to the OIG Hotline via ACL 1) Select “Yes” to make a referral to the OIG Hotline. Reminder: Also check the “Contact OIG” and “Referrals” boxes in the “SMP Actions” section. 2) After saving the complex interaction, this message appears at the top of the screen. You can make a referral to the OIG Hotline using eFile or when logged in to SIRS. As shown here, check the “yes” option to make the referral, and check the “Contact OIG” and “Referrals” boxes in the “SMP Actions” section. When you save the complex interaction, several things will happen automatically. You will receive a confirmation message at the top of the screen. A notification about the complaint will be ed to ACL. The “Yes” will revert back to “No.” The “Date Submitted to ACL” field will fill in with a time stamp. The date will correspond to the last time the case was referred to the OIG hotline. When you return to the complex interaction later, you can see when the case was referred. 3) When you return to the complex interaction later, you can see when the case was referred to the OIG hotline via ACL. mccoy in Ballroom on 8.22 at 1100 no repeat

TIPS: Updating Complex Interactions in SIRS
SMP Casework Trends, Tips, and Tricks 8/22/2018 TIPS: Updating Complex Interactions in SIRS You must log in to SIRS to update a complex interaction to add more information, upload documents, make a referral, close the case, etc. If YOU entered the complex interaction (e.g. using eFile), you can find it in your Tracking Inbox. If SOMEONE ELSE entered the complex interaction, you can find it using the Search feature. mccoy in Ballroom on 8.22 at 1100 no repeat

TIPS: Updating Complex Interactions in SIRS: Multiple Tabs
SMP Casework Trends, Tips, and Tricks 8/22/2018 1 2 TIPS: Updating Complex Interactions in SIRS: Multiple Tabs In SIRS, the complex interaction information is provided on multiple tabs (vs. eFile, where everything is on one screen). Tab 1: Interaction Tab 2: Individual Interaction In SIRS, the complex interaction information is provided on multiple tabs (vs. eFile, where everything is on one screen). When entering or updating complex interactions in SIRS, save the information on each tab before moving to the next tab, or any information entered will be lost. As shown here, the required (and also the “required fields that aren’t marked as required”) must be completed and updated as needed on the Interaction tab before clicking “Continue” to move to the Individual Interaction Tab. mccoy in Ballroom on 8.22 at 1100 no repeat

Updating Complex Interactions In SIRS: Multiple Tabs, continued
SMP Casework Trends, Tips, and Tricks 8/22/2018 Updating Complex Interactions In SIRS: Multiple Tabs, continued 2 3 4 See the SIRS Complex Interactions Job Aid for details. After completing and saving all of the fields on the “Individual Interaction” page, continue to the “Beneficiary” and “Subject” tabs and complete or update all information as applicable for the specific complex interaction. Again, remember that if you enter your complex interaction using eFile, all of these fields are on one page! So, we suggest that you use eFile for the initial entry of your complex interactions, and then log in to SIRS when you need to make updates, upload documents, or close the case. mccoy in Ballroom on 8.22 at 1100 no repeat

TIP: Review Your Work: Full Data PDF
SMP Casework Trends, Tips, and Tricks 8/22/2018 TIP: Review Your Work: Full Data PDF Open the completed complex interaction. Click “Print Full Data PDF.” The report opens as a PDF for you to review, print, or save as needed. To see a summary of your complex interaction and how it will look to ACL… mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 Step 4: ACL Follows Up ACL receives an from SIRS for each case referred. ACL s the SMP to confirm that the case was received. ACL reviews the case in SIRS. ACL discusses the case and reaches out to the SMP as needed. ACL makes a determination and submits the case to the OIG if applicable. After you submit the case in SIRS, we receive an with the case number. Once we start working on your referral, we send a confirmation from the ACL mailbox to the address listed in the “SMP Representative Information” section. If you don’t get the from ACL within one week, contact ACL – we will provide the contact information towards the end of this presentation. Then, we review the case in SIRS, discuss it with others at ACL, and reach out to the SMP who submitted the case as needed. We triage, track and forward the case to the appropriate federal agencies (OIG or FTC) or the SMP with a recommendation. Let’s take a closer look at this process... mccoy in Ballroom on 8.22 at 1100 no repeat

ACL reviews the case in SIRS
SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL reviews the case in SIRS “Full Data PDF” Documents (“Individual Interaction” tab) Tip: OIG Hotline complaint form system limitations: Maximum total file size = 10 MB Compatible file types = .xls, .doc, .pdf, .jpeg, .gif, .png, .tiff In SIRS, we review the case using the “Full Data PDF” and look for document uploads. We save both the Full Data PDF and the documents for further research and follow-up as needed. We also check the size and formats of the documents to make sure they will be compatible for uploading in the OIG Hotline’s complaint reporting system. mccoy in Ballroom on 8.22 at 1100 no repeat

ACL discusses the case and reaches out to the SMP as needed
SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL discusses the case and reaches out to the SMP as needed If additional information is needed, ACL contacts the complex interactions specialist listed in the “SMP representative” section in SIRS. All information and documentation should be “sent” to ACL through SIRS. If you add information or documentation in SIRS, ACL at As needed, the case is discussed within ACL to make a final determination. If we do not have enough information after reviewing the “Full Data PDF”, or if we need additional information such as MSNs, proof of payment etc., we will contact the complex interactions specialist who submitted the case in SIRS to request additional information. We look at the SMP representative section in SIRS to see who submitted the case. Please keep in mind that all information and documentation should be “sent” to ACL through SIRS. Do NOT send this information by . However, if you add information or documentation, ACL at to let us know! Do not provide any details in this other than the case number and your contact information. mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 ACL makes a determination and submits the case to the OIG if applicable If a referral to the OIG Hotline is not needed, ACL s the SMP with a recommendation. If a referral to the OIG Hotline is needed, ACL enters the case in the OIG Hotline’s complaint form. ACL also submits a referral to the FTC if the SMP has not already done so. Tip: Do not ACL to find out about the status of a referral. ACL makes a determination: If a referral to the OIG Hotline is needed, ACL enters the case in the OIG Hotline’s complaint form and submits a referral to the FTC if the SMP has not already done so. Please do not ACL to find out about the status of a referral. If a referral to the OIG Hotline is not needed, ACL s the SMP with a recommendation. mccoy in Ballroom on 8.22 at 1100 no repeat

ACL completes the OIG Hotline complaint form
SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL completes the OIG Hotline complaint form SMP Representative Information After determining that a referral to the OIG Hotline is needed, I enter the complaint in the OIG Hotline complaint form, using the information that you provide to me in SIRS, starting with the SMP representative information. mccoy in Ballroom on 8.22 at 1100 no repeat

ACL completes the OIG Hotline complaint form, continued…
SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL completes the OIG Hotline complaint form, continued… Subject Information Here’s what the subject information fields look like in the OIG Hotline complaint form. mccoy in Ballroom on 8.22 at 1100 no repeat

SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL completes the OIG Hotline complaint form, continued… Complaint Information Health Care Fraud Complaint Medical Identity Theft Complaint Here’s what the complaint information fields look like in the OIG Hotline complaint form. The two types of complaints that are most applicable to SMP cases are: Health Care Fraud Complaint and Medical Identity Theft Complaint. mccoy in Ballroom on 8.22 at 1100 no repeat

SMP Casework Trends, Tips, and Tricks 8/22/2018 ACL completes the OIG Hotline complaint form, continued… Case notes and files are copied from SIRS. Up to 5 files may be uploaded. 10 MB total .xls, .doc, .pdf, .jpeg, .gif, .png, .tiff As mentioned earlier, we copy the case notes and documents from SIRS and upload them directly into the OIG Hotline’s online reporting system. mccoy in Ballroom on 8.22 at 1100 no repeat

Step 5: The OIG Follows Up
SMP Casework Trends, Tips, and Tricks 8/22/2018 Step 5: The OIG Follows Up It can be months or years before a complaint is entirely resolved. Make sure your complainant clearly understands the SMP role: The final outcomes are outside of SMP control! It can be months or years before a complaint is entirely resolved. * Complaints that are referred to law enforcement will take longer to resolve than complaints addressed by CMS through administrative action. The more egregious the suspected fraud or abuse, the longer it is likely to take to resolve. Make sure your complainant clearly understands the SMP role. * It is important to set appropriate expectations of your SMP program. * SMPs can impact the resolution of fraud and abuse by submitting quality referrals; however, the final outcomes are outside of SMP control. mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 Step 6: Closing the Case SMP learns that the referral has been resolved. SMP gets final documentation to show dollar amounts to report. SMP uploads documentation in SIRS and updates the case. Cost avoidance, savings and recoveries are tracked in SIRS when the case is closed. Make sure to get final documentation to show the dollar amounts you will be reporting, then upload the documentation in SIRS and update the case. mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 “Required” Fields to Close a Case in SIRS – Tab 2: Individual Interaction Dollar amounts to report Cost avoidance, savings, and/or expected recoveries Explanation of dollar amounts Include file names of documents and page numbers that show original and revised amounts. Documentation Upload files to document cost avoidance, savings, and/or expected recoveries. For details about which documentation is needed, see the OIG Report Webinar. Additional Case Notes Status of Interaction Date of Last Status Update To close the case, log in to SIRS and go to the “Individual Interaction” tab. R mccoy in Ballroom on 8.22 at 1100 no repeat

8/22/2018 Closing a Case in SIRS See the SIRS Complex Interactions Job Aid and the OIG Report Webinar for details. Record any savings, expected recoveries, or cost avoidance, along with a brief explanation. In the Explanation field, include the file names of the documents that show the cost avoidance, savings, and recoveries, as well as the page numbers that show the original amounts and revised amounts. Upload any files needed to document the cost avoidance, savings, and recoveries. For details about which documentation is needed, see the OIG Report Webinar 2017. Update the case notes as needed with final information. Update the Status of Interaction and Date of Last Status Update. Save your updates! See the SIRS Complex Interactions Job Aid for details. mccoy in Ballroom on 8.22 at 1100 no repeat

SIRS Data Summary January – July 2018
Number of Individual Interactions: 95,433 Number of Complex Interactions: 14,723 15.4% of all interactions Number of Cases Referred to OIG via ACL: 254 1.8% of all complex interactions Number of Cases Referred to OIG: 218 86% of all interactions referred to OIG via ACL

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