1. DSDS Quality Assurance Unit State of Alaska, Dept. of Health and Social Services Division of Senior and Disabilities Services (DSDS) Quality Assurance Unit 3601 C Street, Suite 310, Anchorage, Alaska 99503 Fran Arseneau, CPC, Manager Quality Assurance Unit

2. Division of Senior and Disabilities Services  Medicaid Waivers: Adults with Physical Disabilities, Children with Complex Medical Conditions, Developmental Disabilities, Older Alaskans  Personal Care Programs: Agency Based and Consumer Directed  Skilled Nursing Facilities  Developmental Disabilities Grant Programs  Senior Care Senior Information Office  Senior Grant Programs  Adult Protective Services

3. The DSDS Quality Assurance Program  The Quality Assurance (QA) Unit is the lead DSDS unit responsible for ensuring the provision of consumer focused quality services and leads the Division’s efforts toward continuous improvement of services provided to consumers.  The QA Unit is also responsible for DSDS Program Integrity.

4. DSDS Quality Assurance Activities  Informing consumers of their rights and responsibilities  Collecting feedback on the quality of services provided  Providing technical assistance  Collaborating with other DSDS units in the implementation of a DSDS quality assurance plan  Influencing and supporting DSDS quality improvement initiatives  Responding to and investigating complaints of inappropriate service provision or non-compliance with program guidelines  Evaluating program performance through surveys and audits

5. Quality Assurance Audit Activities

6. Audit Objectives  To evaluate provider and/or recipient compliance with Medicaid and Grant program rules and regulations  To safeguard recipient health and welfare  To ensure recipients have access to services  To evaluate provider capacities and capabilities  To ensure recipients understand their rights and responsibilities  To evaluate outcomes and recipient satisfaction  To identify and quantify questionable billing practices or program utilization patterns  To assist the DSDS Policy and Program Review leadership in developing policies and procedures  To identify areas for Program improvements

7. Program Audit Process  One purpose of a program audit is to evaluate compliance with applicable statutes, regulations, certification requirements, compliance with the Medicaid provider agreement and applicable Medicaid provider billing manuals.  Another purpose of a program audit is to provide information and data to assist DSDS in developing and implementing regulatory and policy guidelines that improve fiscal accountability and quality of services.

8. The Audit Process

9. Audit Process  Select the Sample - Must be statistically valid - May be based on provider or recipient sample  Notify and request records - May be initiated without notice  Evaluate the records - Do the records meet standards?  Document initial findings  Notify regarding initial findings and additional record review - Provide chance to comment and/or provide additional documentation  Amend the findings  Reconcile amended findings

10. Reconciliation of Findings  Provider/Recipient education  Corrective Action Plans  Recommendations for program and/or policy improvements  Referrals to other entities or for implementation of sanctions

11. COMMON FINDINGS  Un-documented services  Inadequate or deficient records  Program violations such as family/guardians providing services, client rights ignored or violated  Licensure or certification violations  Inappropriate billing practices (i.e., incorrect procedure codes and/or modifiers, duplicate claims payments)  Duplicate claims payments  Deficient or non-existent financial records  Inaccurate provider certification or Medicaid enrollment information

12. PROGRAM/POLICY IMPROVEMENTS  System problems identified  Medicare cross over claims processing  Provider specific assistance  Focused training needs  Policy and program review  Appeals issues

13. AUTHORITY Health Information, Portability and Accountability Act of 1996  HIPAA provides exception for state access to Private Health Information for: –Audits, monitoring, and licensing & certification - 45 CFR 160.203 –Protects whistleblowers - 45 CFR 164.502(j) –Permits PHI disclosure for:  Audits  Investigations  Inspections  Licensure or disciplinary actions  Civil, administrative, or criminal proceedings  Other Government functions authorized by law  45 CFR 164.512 (a) & (d)

14. FEDERAL AUTHORITIES  42 CFR part 431 – State Organization and General Administration  42 CFR Part 455 – Program Integrity: Medicaid  42 CFR Part 456 – Utilization Control  42 CFR Part 1002 – Program Integrity  Health Insurance Portability Accountability Act (HIPAA) 1996

15. STATE AUTHORITIES  AS 47.05.021 Medical Assistance Fraud  AS 47.07.074 Audits and Inspections  7 AAC 43.005 to 1990 Alaska Medicaid Regulations –7 AAC 43.027 Restriction of Recipient Choice of Providers –7 AAC 43.030 Requirements for Provider Records –7 AAC 43.032 Request for Records –7 AAC 43.035 Eligible Providers –7 AAC 43.065 Medical Provider Agreement –7 AAC 43.067 Reviews and Audits –7 AAC 43.068 Use of Statistical Sampling –7 AAC 43.081 Recovery of an Overpayment –7 AAC 43.085 Provider Appeals –7 AAC 43.950 Grounds for Sanctioning Providers

16. MEDICAID WAIVER AUTHORITY  Federal Assurances  1915 (c) Medicaid Waiver Assurances  State Regulation  7 AAC 43.1000 to 1110 Medical Home and Community- Based Waiver Services

17. Resources On the Web  State of Alaska: http://www.state.ak.us http://www.state.ak.us  Division of Senior and Disabilities Services: http://www.hss.state.ak.us/dsds http://www.hss.state.ak.us/dsds  Division of Health Care Services: http://www.hss.state.ak.us/dhcs http://www.hss.state.ak.us/dhcs  First Health Services Corporation http://alaska.fhsc.com http://alaska.fhsc.com  Department of Law - Medicaid Fraud Control Unit http://www.law.state.ak.us/criminal/ospa/medfraud

18. Resources On the Web  State of Alaska - Statutes and Regulations http://www.legis.state.ak.us/folhome.htm http://www.legis.state.ak.us/folhome.htm  Centers for Medicaid and Medicare [CMS] - Medicaid http://www.cms.hhs.gov.gov/medicaid http://www.cms.hhs.gov.gov/medicaid  OIG - Compliance Guidance For Individual, Small Group Practices http://www.hhs.gov/oig/modcomp/cpc.pdf http://www.hhs.gov/oig/modcomp/cpc.pdf

19. Questions ?? Fran Arseneau, CPC, Manager Quality Assurance Unit (907) 269-3654 Fran_Arseneau@health.state.ak.us