1. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION State Program Update Panel PHA Annual Conference Laurie Rock Pamela Mailey May 17, 2012

2. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Explain the Bureau of Program Integrity responsibilities Discuss Medical Assistance regulatory requirements Discuss relevant elements of Affordable Care Act Providers’ responsibility to screen employees Common review findings Questions Discussion Points

3. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Bureau of Program Integrity Federally mandated function to: Prevent, identify and combat fraud, waste and abuse within the Medical Assistance program Monitor providers’ compliance with Medical Assistance regulations and requirements Ensure Medical Assistance recipients receive quality care and do not abuse their benefits

4. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 Presentation Title Presenter Date OFFICE OF ADMINISTRATION Bureau of Program Integrity Responsibilities include: Evaluate services and claims for compliance Monitor recipient overuse or abuse of services Refer to civil and criminal agencies Enforce administrative actions Conduct outreach and education

5. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Bureau of Program Integrity Fraud an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person Abuse provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for health care Waste not currently defined in federal Medicaid regulations generally understood to encompass the over-utilization or inappropriate utilization of services and misuse of resources, and typically is not a criminal or intentional act

6. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Regulations and Other Instructions Federal Program integrity – 42 CFR Part 455 Utilization control – 42 CFR Part 456 State – 55 PA Code Chapter 1101 – General Provisions Chapter 1150 – Payment Policies Chapter 1130 – Hospice Chapter 1249 – Home Health MA Provider Bulletins 37-02-01 – findings from hospice reviews Provider Handbooks/Billing Instructions

7. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Regulations General Provisions – 55 PA Code §1101 These regulations apply to all enrolled providers Based on state and federal laws Some important sections include: 55 Pa Code §1101.51 (e) – records must: Medical and fiscal records must disclose nature and extent of services Contain documentation of medical necessity of ordered, rendered and prescribed services Be available for review/copying Be retained for a minimum of 4 years

8. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Regulations Some important sections include: 55 Pa Code §1101.75 (a) and (b) – Provider prohibited acts: Violations of these are the most serious Some violations are considered criminal acts subject to investigation and prosecution by Medicaid Fraud Control Unit Subject to enforcement actions by DPW and restitution

9. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Regulations Some important sections include: 55 Pa Code §1101.66 – Compensable services – must be: Medically necessary Not in excess of need Not solely for recipient convenience No payment for services or items by providers terminated from the Medical Assistance program

10. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Affordable Care Act Level of screening will depend on risk of fraud, waste, & abuse Limited risk Verify compliance with applicable federal and/or state requirements License verification Database checks – e.g. EPLS, LEIE, SSI master death file Moderate risk (includes hospice organizations) All limited risk requirements and On-site visits – pre- and post enrollment High risk (includes newly enrolling home health and DME suppliers) All limited and moderate risk requirements and Conduct criminal background checks and fingerprinting (states not required to implement until additional guidance is issued) Provider Enrollment Screening

11. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Affordable Care Act Adjustment of risk levels Level of risk must move to high if a payment suspension is imposed (based on credible allegation of fraud) Level of risk must move to high if provider has been excluded in the past 10 years Level of risk must move to high for 6 months following any temporary enrollment moratoria MA may rely on results of screening from: Medicare contractors MA or CHIP agencies from other states Revalidation – States must revalidate all enrolled providers every 5 years

12. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Compliance Programs HHS is required to establish compliance program requirements and timeline for establishment of core elements. Compliance program is a condition of enrollment for Medicare, Medicaid, and CHIP providers and suppliers. Enrollment and NPI of Ordering or Referring Providers All ordering and referring physicians and other professionals under the State plan or waiver program must be enrolled in Medicaid as a participating provider. NPIs must be on all claims for payment of ordering and referring physicians and other professionals. Affordable Care Act

13. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Reporting and Returning Overpayment Providers, suppliers, Medicaid MCOs, Medicare Advantage plans, and PDP sponsors must report and return overpayments to HHS, the State, or a Medicare intermediary or carrier by the later of: 60 days of identification of overpayment, or the due date of the cost report. Treble damages and CMPs up to $50K for knowing failure to return overpayments on time. Knowing and failure to report may also be considered a false claim under the Federal False Claims Act. Affordable Care Act

14. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Payment Suspension/Credible Allegation of Fraud HHS may suspend and the State must suspend payments to individuals or entities based upon credible allegations of fraud, unless HHS/the State determines there is good cause not to suspend payments. Applies to Medicare and Medicaid. Affordable Care Act

15. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Face to Face Encounters Proposed rules for Medicaid issued July 12, 2011 (42 CFR part 440) Must occur and be documented 90 days prior or 30 days after order for home health or DME (for Medicaid) Can be done by a physician or non-physician practitioner Nurse Nurse practitioner Clinical nurse specialist Certified nurse midwife (not allowable for DME) Physician assistant However, documentation of the face-to-face encounter is the physician’s responsibility Affordable Care Act

16. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Recovery Audit Contractor Program The State must establish a RAC Program consistent with State law by 1/1/12. RAC must identify overpayments and underpayments. The State must pay RACs on a contingency fee basis for recoveries of overpayments. State appeals procedures must apply. RACs must coordinate with other reviewing entities and law enforcement.

17. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Medical Assistance Bulletin 99-11-05 Provider Screening of Employees and Contractors for Exclusion and Effect of Exclusion 42 CFR 1001.1901 (b) - ”no payment will be made by Medicare, Medicaid, or any other Federal Health Care program for any item or service furnished, by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual….” Providers should screen monthly Sources to use for screening checks: PA Medicheck List List of Excluded Individuals/Entities (LEIE) – federal listing Excluded Parties List System (EPLS)

18. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Hospice Reviews Include review of: Hospice care Pharmacy DME Inpatient services Home health services

19. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 Common Violations OFFICE OF ADMINISTRATION Lack of Medical Necessity Inappropriate Level of Care/Services Inappropriate Revocations

20. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION Missing/Incomplete MA 372 Certification of Terminal Illness Form Election of Hospice Form MA 373 not completed Incomplete Records Current Findings/violations are consistent with past review periods. Record Keeping Violations

21. OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 Questions OFFICE OF ADMINISTRATION Contact Information: Laurie Rock Director Bureau of Program Integrity 717-772-4606 Lrock@pa.gov Pamela Mailey Director Division of Program and Provider Compliance 717-772-4606 Pmailey@pa.gov