1. PROGRAM INTEGRITY AND PROVIDERS IN MEDICAID MANAGED CARE Julia B. Sinclair, MSW, LCSW Sr. Director, Quality and Integrity Operations Smokey Mountain Center Amanda Maultsby Willett, MS, CHC Regulatory Compliance Manager East Carolina Behavioral Health

2. TRAINING OBJECTIVES 1.Define purpose of Program Integrity in Medicaid Managed Care Organizations 2.Define key Program Integrity related terms and acronyms 3.Describe responsibilities of consumers, provider agencies, LME/MCO, DMA, MID, and federal oversight agencies in regards to Program Integrity activities 4.Differentiate between Program Integrity Investigation and Routine Monitoring 5.Differentiate between types of investigations conducted by the LME/MCO 6.List Program Integrity Referral Sources 7.Differentiate between types of Program Integrity Investigations 8.Define Program Integrity investigation Process 9.List possible outcomes from Program Integrity investigations 10.Identify laws/Regulations/Statues related to Program Integrity

3. PURPOSE OF PROGRAM INTEGRITY

4. QUALITY PROVIDERS Improved outcomes for consumers Reduced oversight for provider Confidence in network for LME-MCOs

5. FISCAL ACCOUNTABILITY Investigate provider billing practices Ensure dollars are spent in a way that complies with federal and State mandates Ensure that tax dollars buy appropriate, quality care for consumers

6. PI DEFINITIONS AND ACRONYMS

7. AcronymMeaning PIProgram Integrity LME/MCOLocal Management Entity/Managed Care Organization DMADivision of Medical Assistance MIDMedicaid Investigations Division CMSThe Centers for Medicare & Medicaid Services OIGOffice of Inspector General EOBExplanation of Benefits * Additional Acronyms and Definitions have been provided in “Acronym & Definition Document

8. FRAUD Fraud is defined by Federal law ( 42 CFR 455.2) as "an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person

9. ABUSE Abuse is defined by Federal law ( 42 CFR 455.2) as 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. It also includes recipient practices that result in unnecessary cost to the Medicaid program.

10. PROGRAM INTEGRITY IS THE RESPONSIBILITY OF __________

11. Everyone Consumers Provider Agencies and their Employees LME/MCO and their Employees State Oversight Agencies and Employees Federal Oversight Agencies and Employees Other Stakeholders

12. CONSUMER’S RESPONSIBILITY Use Medicaid responsibly Coordination of Benefits (COB) individuals should inform provider, LME/MCO and DSS of all insurance coverage Identify suspicious practices of providers Observation Complete EOB process by LME-MCOs Identify suspicious behavior of other recipients

13. PROVIDER AGENCY’S RESPONSIBILITY Be familiar with and follow rules/regulations Be familiar with and provide services within clinical coverage policies and best practice guidelines Coordination of Benefits (COB) responsible for gathering all insurance information from the individuals they serve, report this to the LME/MCO and bill third party payors

14. PROVIDER AGENCY’S RESPONSIBILITY Self-audits and self-reporting Comply with monitoring and investigations

15. LME/MCO RESPONSIBILITIES Be familiar with and follow rules/regs Be familiar with and educate providers and consumers regarding clinical coverage policies and best practice guidelines Routinely monitor providers in their provision of services

16. LME/MCO RESPONSIBILITIES Coordination of Benefits (COB) verify any third party payors and pay only items for which Medicaid is responsible Accept and look into all referrals of suspicious practices of recipients and providers Maintain integrity and professionalism through referral and investigation process

17. OTHER AGENCIES’ RESPONSIBILITIES State Oversight Agency DMA-PI Division of Medical Assistance Program Integrity Law Enforcement Agency MID Division Medicaid Investigations Division

18. OTHER AGENCIES’ RESPONSIBILITIES Create and enforce consistent guidelines for PI Enforce and follow federal rules/regulations Educate LME/MCOs, providers and consumers regarding PI practice guidelines Provide guidance to LME/MCOs in their PI efforts Accept referrals of suspicious practices of LME/MCOs, recipients and providers Investigate appropriate referrals

19. FEDERAL OVERSIGHT AGENCIES’ RESPONSIBILITIES Centers for Medicare and Medicaid Services (CMS) (www.cms.gov) “The Centers for Medicare & Medicaid Services (CMS) is committed to combating Medicaid provider fraud, waste, and abuse which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid recipients.” 5-year Comprehensive Medicaid Integrity Plan

20. Office of Inspector General (OIG) www.oig.hhs.gov “Since its 1976 establishment, the Office of Inspector General of the U.S. Department of Health & Human Services (HHS) has been at the forefront of the Nation's efforts to fight waste, fraud, and abuse in Medicare, Medicaid and more than 300 other HHS programs.” certifies, and annually recertifies DMA PI analyzes PI performance based on 12 performance standards develops, implements and publishes the annual workplan FEDERAL OVERSIGHT AGENCIES’ RESPONSIBILITIES

21. Division of Social Services Juvenile Justice School Systems Medical Community OTHER STAKEHOLDERS’ RESPONSIBILTIES

22. INVESTIGATION –VS- MONITORING

23. MONITORING STANDARD OPERATING PROCEDURE Types Routine Focused Outcomes Report of Findings Plans of Correction Technical Assistance Referrals for investigation

24. INVESTIGATION Based upon an allegation Compliance issues suspected Higher level sanctions possible

25. REFERRALS

26. INTERNAL REFERRALS Internal Staff Electronic Entry Website Alpha/CI Internal Committees Data Analytics EOB

27. EXTERNAL REFERRALS Hotlines DHHS Mail Electronic Entry Consumers Stakeholder Access Line/Call Center

28. INVESTIGATIONS

29. CONTINUUM OF INVESTIGATIONS Grievance Provider Network Program Integrity

30. ANNOUNCED Desk Review Onsite UNANNOUNCED Onsite

31. INVESTIGATION PROCESSES

32. DESK REVIEW INVESTIGATION PROCESS 1.Screen the Referral 2.Additional Data Mining 3.Determine Type of Investigation Necessary 4.Create an Investigative Plan

33. DESK REVIEW PROCESS CONTINUED… 5. Determine record sample 6. Create record request and send to provider 7.Inventory/Date stamp/catalog records when they arrive 8.Review records completing documentation 9.What happens when records are not submitted according to request

34. DESK REVIEW PROCESS CONTINUED… 10.Summarize results 11.Issue Letter - Notice of Overpayment (copy Finance and PN) - No Findings Letter 12. Reconsideration when requested 13. Issue final decision (copy Finance and PN)

35. ANNOUNCED SITE VISIT INVESTIGATION PROCESS 1.Screen the Referral 2.Additional Data Mining 3.Determine Type of Investigation Necessary 4.Verify site of investigation

36. ANNOUNCED SITE VISIT CONTINUED… 5.Create investigation plan 6.Determine record sample 7.Create record request and send to provider with details of onsite (advance notification) 8.Introduction or opening conference onsite 9. Review records completing documentation 10. Exit conference

37. ANNOUNCED SITE VISIT CONTINUED… 11. Summarize results 12.Issue Letter(copy Finance and PN) - Notice of Overpayment - No Findings Letter 13.Reconsideration when requested 14. Issue final decision (copy Finance and PN)

38. UNANNOUNCED SITE VISIT INVESTIGATION PROCESS Same as Announced Site Visit Process without advance notification Introduction letter and record request brought to agency site rather than mailing

39. FOLLOW UP PROCESSES

40. Local Reconsiderations Provider Payments Contested Agency Final Decisions Reporting to Other Oversight Agencies DMA PI Process MID Process

41. POSSIBLE OUTCOMES

42. POSSIBLE OUTCOMES OF INVESTIGATIONS Sanctions Grid

43. LAWS/REGULATIONS/STATUES RELATED TO PROGRAM INTEGRITY

44. FEDERAL ANTI-KICKBACK STATUE Health care providers cannot offer, pay, solicit, or receive anything of value for referral of items or services paid for by Medicare, Medicaid, or other federal health care programs Felony Conviction punishable up to $25,000 in fines, imprisonment, or both

45. FALSE CLAIMS ACT (FCA) Law that was established to punish persons or entities that file false or fraudulent claims for payment by government agencies Financial penalties: $5,000 - $11,000 per claim

46. WHISTLE BLOWER ACT Anyone who reports fraud and/or abuse to the federal government can claim protection from retaliation under the Whistle blower Act. Additionally, if any money is recovered as a result of the report filed by a whistle blower, that person could file a lawsuit that can result in receiving a portion of the recovered money.

47. DEFICIT REDUCTION ACT Designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries. Requires compliance for continued participation in the programs by agencies providing billing five million (5mm) or more annually. Felony conviction and a fine up to $25,000 and/or imprisonment for no more than 5 years if false statements

48. CIVIL MONETARY PENALTIES LAW Intended to prevent health care providers from improperly influencing how Medicare and Medicaid consumers select their care provider Penalties are imposed when entities or individuals offer or give something of value to Medicare/Medicaid consumers so that they will choose a particular provider or supplier Fines of up to $50,000 per wrongful action

49. HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) Regulates the way certain health plans, health providers, and health clearinghouses (covered entities) handle Protected Health Information (PHI). Creates Federal standards for maintaining the confidentiality of PHI and governs its use and disclosure Civil penalties up to $100/violation up to $25,000/year Criminal penalties $50,000 and 1yr imprisonment up to $250,000 and 10yrs imprisonment

50. RESOURCES Key Laws, Regulations, Statues Grid Definition and Acronym Spreadsheet LME/MCO Program Integrity Contact Information Standardized Sanctions Grid CMS Fact Sheet OIG Work Plan Example Sheet

51. QUESTIONS??