1. Overview of the Office of the Inspector General (OIG) in the Context of Comprehensive Community Services (CCS)
Kari Engelke, Assistant Inspector General
Brad Dunlap, Senior Auditor
May 9, 2019

2. Overview of the OIG
Kari Engelke, Assistant Inspector General

3. Topics Overview of the Office of the Inspector General (OIG)
Structure
Audit programs
Sample selection
Extrapolation
Comprehensive Community Services (CCS) audits
Tips for a positive audit experience

4. DHS Office of the Inspector General

5. Data Analytics Section (DAS)
Created in October 2016.
Primary functions are consolidated data analytics, data mining and providing information systems support staff.
Responsible for developing meaningful, action-oriented info and data to identify improper payments.
Leads the implementation of the new data analytics system.

6. Internal Audit (IA)
Performs independent, objective assurance and consulting activities including:
Investigations of improper activities by employees.
System and operational control audits.
In a typical year, IA reviews 500 independent audits of contracted agencies

7. Fraud Investigation Recovery and Enforcement (FIRE) Section
Provides oversight of recipient fraud prevention efforts in Medicaid and FoodShare.
Seeks to prevent Women, Infants, and Children (WIC) program vendor fraud.
Works with county partners and administers the statewide Fraud Prevention and Investigation Program.

8. Medical Audit Review Section (MARS)
Objectives and responsibilities of MARS:
Conduct on-site and desk reviews of Medicaid providers.
Recover unauthorized Medicaid payments due to:
Services not medically necessary.
Services fail to meet professionally recognized standards for health care.

9. Types of Audits-MARS Personal Care and Home Health
Nurses in Independent Practice
Physicians
Dental
Lab
Therapy
Anesthesia
Certificate of Need (CON)

10. Types of Audits-MARS (continued)
Chiropractic
Hospice
Mental Health
Obstetrical Services

11. Program Audit Review Section (PARS)
Objective and responsibilities of PARS:
Conduct on-site and desk reviews and investigations of Medicaid providers.
Determine compliance with state and federal laws, rules, and regulations to detect fraud, waste, and abuse of the Medicaid program.
Recover unauthorized Medicaid payments.

12. Types of Audits-PARS (continue)
Date of Death
Durable Medical Equipment (DME) and Disposable Medical Supplies (DMS)
Recovery Audit Contract (RAC)
Pharmacy Audits
Prenatal Care Coordination (PNCC) and Child Care Coordination (CCC)

13. Types of Audits-PARS Comprehensive Community Services (CCS)
Include, Respect, I Self-Direct (IRIS)
Electronic Health Record (EHR) Incentive program
Federally Qualified Health Center (FQHC) and Rural Health Care (RHC)
Health maintenance organizations (HMOs)
Family Care managed care organizations (MCOs)

14. Reasons to Audit Changes to policy or system change New programs
Complaints
General program integrity oversight
Watch lists including:
Affordable Care Act (ACA) visit findings
High-risk providers who have opened a new business
High-risk service types
Requested compliance monitoring

15. Types of Audits Focused audits review one specific issue. For example:
Inpatient overlap.
Claims that exceed the prior authorization.
Duplicate billing.
Comprehensive audit review multiple regulations and policies.

16. Audit Scope The following factors influence audit scope: Provider type
Recent claim submissions
Complaint timeframe
Policy changes or updates

17. Sample Size Intentional selection Complaint subjects Agency size
Percentage of members associated with the provider
Members receiving services at the same address
Outliers

18. Record Collection OIG obtains records by:
Sending a records request letter.
Conducting an on-site record collection.

19. Record Review
The auditor completes a review of the records to ensure compliance with:
Wisconsin Administrative Code.
Medicaid Handbooks.
1915(c) Home and Community Based Services (HCBS) waivers (long-term care programs).
Contracts (HMOs and MCOs).
Medicaid Provider Agreement.

20. Preliminary Review Stage
The provider receives either a No Findings letter or a Preliminary Findings letter.
If the provider is in agreement, they can respond by:
Submitting payment.
Requesting payments be withheld.
Establishing a payment plan.
If the provider disagrees, they can submit additional documentation.

21. Rebuttal
The auditor reviews documentation submitted in timely response to the Preliminary Findings letter.
The auditor adjusts findings and recoupment amounts appropriately.
When an audit recoupment amount is reduced, the auditor mails an Amended Preliminary Findings letter.

22. Notice of Intent to Recover (NIR) Stage
NIR letters are mailed in the following situations:
The provider does not submit additional documentation in response to the Preliminary Findings or Amended Preliminary Findings letters.
The audit findings do not change after reviewing rebuttal documentation submitted in response to the Preliminary Findings.
After review of documentation submitted in response to the Amended Preliminary Findings letters.

23. Responding to an NIR Letter
The provider can respond to the NIR letter in one of several ways:
Submitting payment.
Requesting payments be withheld.
Establishing a payment plan.
Requesting a hearing from the Division of Hearing and Appeals (DHA) by submitting, in writing, the basis for contesting the proposed recovery.

24. Provider’s Right to Appeal
Appeals process:
An attorney in the Office of Legal Counsel (OLC) is assigned to the case.
The provider and the auditor communicate to see if the case can be resolved prior to litigation.
If a resolution is not agreed upon, an Administrative Law Judge (ALJ) will be assigned to the case.
A hearing will be scheduled with the ALJ.

25. Credible Allegations of Fraud (CAF)
Credible Allegation of Fraud (CAF) steps:
Compile background information on the audit.
Gather evidence and create exhibits that illustrate the potential fraud.
Complete the Medicaid Fraud Control and Elder Abuse Unit (MFCEAU) referral form.
Present the case to OIG management and legal counsel.
If approved, the case is referred to the MFCEAU.

26. Sanctions and Terminations
OIG has the authority to sanction or terminate providers who have violated Wis. Admin. Code § DHS or
This most frequently occurs when providers have audits with repeated findings.
Imposed sanctions have included requiring a third-party biller or compliance director.
Termination means the provider is terminated from the Wisconsin Medicaid program.

27. Extrapolation
Extrapolation refers to the concept of projecting a sample error rate to a population.
OIG’s Unified Program Integrity Contractor (UPIC), AdvanceMed, does all the statistical analysis required for statistically sound extrapolation.
OIG has used extrapolation in cases where the findings are significant and there is reason to believe the findings would be present throughout the population.

28. Comprehensive Community Services (CCS) Audits
Brad Dunlap, Senior Auditor

29. Audit Approach
Auditors review CCS claims to determine their compliance with written Medicaid and CCS guidelines and regulations.
OIG examines CCS services that were billed as either psychosocial rehabilitation or provider travel time.
When discrepancies are found, OIG seeks to recover payments for those services.

30. Documentation Reviewed
Claim information
Application
Admission agreement
Authorization
Assessment
Service plans
Case notes
Travel documentation
Staff qualifications and training documentation

31. Relevant Wis. Admin. Code
Ch. DHS 36 – CCS-specific code
Ch. DHS 105 – certification requirements
Ch. DHS 106 – requirements for maintaining appropriate documentation
Ch. DHS 107 – non-covered services

32. Relevant Sections of the Medicaid Handbook
Topic #824 – Services that do not meet program requirements
Topic #17117 – CCS program requirements
Topic #17137 – CCS Program – service array
Topic #17219 – Claim submission for CCS
Topic #17277 – Procedure codes

33. Audit Results
Audit findings could occur in 20 different, broad categories.
These 20 categories are broken into sub-categories, depending on the specific finding.
The following table demonstrates data collected during a series of 29 CCS audits completed in 2016 with scopes.

34. Audit Results

35. Audit Results - Comprehensive Assessment
The Assessment Summary did not indicate if there were significant and unresolved differences of opinion identified during the completion of the assessment.
The Assessment Summary did not include signatures of all persons present at the meetings being summarized.
The Assessment did not address one or more of the 16 domains of functioning required by Wis. Admin. Code.

36. Audit Results - Service Plan
The service plan did not indicate that the service planning process was explained to the consumer, legal guardian, or family member.
The attendance roster did not contain the names, signatures, meeting dates, addresses, and telephone numbers of each person attending the service planning meetings.
The service provider and the source of payment was not specified within the service plan.

37. Tips for a Positive Audit Experience
Maintain all required employee and member documentation and records.
Maintain organized records so that you can find the documentation you need.
Train your employees to provide services and complete their paperwork in a timely manner, using the applicable Wis. Admin. Code and Medicaid Handbook as a guide.

38. Tips for a Positive Audit Experience
Be mindful of dates for submitting initial documentation, rebuttal documentation, and filing an appeal. All pertinent dates are in the letters.
Ask questions—OIG wants you to be successful CCS providers and we are willing to answer questions that you have.

39. Current CCS Activity
Workgroup with partners in the Division of Quality Assurance (DQA) and the Division of Care and Treatment Services (DCTS) to ensure unified responses to questions and concerns.
Responding to complaints.
Further development of CCS-related program integrity strategies, including post-payment audits, pending implementation of “County” OIG team.

40. Questions