CMS New Mega-Regs & Program Integrity: Key Must-Know Provisions Spring Conference, Session 19 April 25, 2017

Transcription

1 CMS New Mega-Regs & Program Integrity: Key Must-Know Provisions Spring Conference, Session 19 April 25, 2017 Selenna Moss, Chief Compliance/QM Officer Andrew Walsh, Chief Legal Officer

2 Explore key provisions in the CMS Mega- Regs and NC DMA-PIHP contract(s) related to Program Integrity (PI) including implementation dates, that might impact attendees. Review tips, trends, and tools for PI operations. 2

3 Overview of the Medicaid Managed Care Mega- Regs Review Key Provisions of the Mega-Regs and implementation timeframes Review Key State Medicaid Contractual Obligations of MCOs Discuss challenges and opportunities Provide resources, tips and tools 4/21/2017 3

4 Of those present, how many represent: MCOs Providers State Other What would you like to gain from today s session? 4/21/2017 4

5 Managed Care v. Fee for Service (FFS) 42 CFR, Part 438 vs Part 431 Compliance vs. Program Integrity (PI) Closed Provider Network < Medical Assistance Plan Enrollment, credentialing, contracting 4/21/2017 5

6 4/21/2017 6

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9 Proposed Rule: June 01, 2015 Final Rule: May 6, st Comprehensive Update since 2002 Strengthens Federal Expectations of State s MMC Programs 4/21/2017 9

10 "aligns, where feasible, many of the rules governing Medicaid managed care with those of other major sources of coverage" e.g., Medicare Advantage, private insurers/commercial health plans, etc. "strengthens actuarial soundness payment provisions to promote the accountability of Medicaid managed care program rates" 4/21/

11 "promotes the quality of care" "ensures appropriate beneficiary protections and enhances policies related to program integrity" "Adopts procedures and standards to ensure accountability and strengthen program integrity safeguards to ensure the appropriate stewardship of funds" 4/21/

12 42 CFR, 438 Subpart H PI Safeguards Statutory basis, basic rule, and applicability State responsibilities Data, information, and documentation that must be submitted. 4/21/

13 42 CFR, 438 Subpart H PI Safeguards cont Source, content, and timing of certification Program integrity requirements under the contract Prohibited affiliations. 4/21/

14 Additional PI Safeguards The Mega-Regs Updated from 2 to now 12 Sections of the Social Security Act supporting PI regulatory changes. Replaced excluded with debarred Relocated the basic rule that a Managed Care Entity (MCE) can be paid Medicaid $$ only if it complies with the PI regs Clarified some PI regs go into effect 7/1/17 and others 7/1/18. 4/21/

15 Additional PI Safeguards cont. Section 1128J(d) of the Social Security Act Added as 1 of the 12 Section under "Requires that persons who received an overpayment under Medicaid report and return the overpayment within 60 days after the date on which the overpayment was identified." 4/21/

16 Additional PI Safeguards The Mega-Regs completely replaced this section regarding State responsibilities. Specifically, States must, by 7/1/17 (except * = 7/1/18): Monitor MCE compliance with the PI regs screen and enroll, and periodically [at least every 5 years] revalidate, all network providers of [MCEs] * [OON excluded] Review ownership and control disclosures submitted by the MCEs. Confirm federal database checks of the MCEs and others Audit MCE encounter and financial data at least once every 3 years. receive and investigate information from whistleblowers Post on its web certain reports and information Have COI/contracting integrity safeguards. Ensure MCE is not outside U.S. and claims paid outside U.S. are excluded from capitation rates. 4/21/

17 Additional PI Safeguards & Data, information, and documentation that must be submitted Source, content, and timing of certification. 4/21/

18 Additional PI Safeguards Heart of PI in Mega-Regs Dictates minimum program integrity requirements under State contracts with MCEs See Handout or statute at 4/21/

19 Additional PI Safeguards Prohibited Affiliations Somewhat convoluted structure, but reg basically bans MCE from *knowingly* having certain relationships Individuals or entities: debarred, suspended, or otherwise excluded from federal procurement (including affiliates) Excluded from federal health care program Relationships: MCE D&O, partner, subcontractor, owner (>5%) or network provider State must report noncompliance to feds and can continue/renew only with Secretary and OIG permission 4/21/

20 PIA, QIA & MLR PI cost a service? MLR measures service dollars as ratio of total dollars. Proposed Rule allowed PI fraud prevention activities (PIA) to go into numerator up to a cap. Concept was to incent MCEs to prevent and monitor FWA, not just seek recoveries after an act of FWA. CMS changed mind in Final Rule, but left door open: we are finalizing 438.8(e)(4) to incorporate standards for fraud prevention activities in the MLR calculation as adopted for the private market at 45 CFR part 158. Quality Improvement Activities (QIAs) in the MLR numerator did survive the comment period. 4/21/

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22 DRAFT CONTRACT Trickle Down Obligations SECTION General [3 clauses] PROGRAM INTEGRITY 14.2 Fraud and Abuse [15 clauses, 4pp] 14.3 Provider Payment Suspensions and Overpayments [7 clauses] 4/21/

23 14.1 General PIHP shall: 1. Comply with applicable federal law, including provider payments and detecting fraud and abuse. 2. Implement PI policies and procedures. 3. Include PI requirements in its contracts with closed network providers. 4. investigate all grievances and/or complaints received alleging fraud, waste or program abuse and take the appropriate action. 4/21/

24 14.2 Fraud & Abuse: Compliance Plan PIHP must have a DMA annually approved written Compliance Plan consistent with 42 CFR , designed to guard against fraud and abuse, including at a minimum: A plan for training, communicating with and providing detailed information to staff, contractors and providers about fraud and abuse policies and procedures and the False Claims Act; Provision for prompt response to offenses identified through internal and external monitoring, auditing and development of corrective action initiatives; Enforcement of standards through well-publicized disciplinary guidelines; and Provision for full cooperation with any investigation conducted by Federal or State authorities, including DMA or MFCU/MID. 4/21/

25 14.2 Fraud & Abuse: Compliance Officer & Committees PIHP must have: 1. a Compliance Officer however named who retains authority to report directly to the CEO and the Board of Directors as needed irrespective of administrative organization. 2. Two regulatory compliance committees: One on the board of directors and the other at the PIHP senior management level. 4/21/

26 14.2 Fraud & Abuse: PI Unit, Contact & Meetings PIHP must have: 1. PIU: special investigations/pi unit, however named, responsible for PI activities, including identification, detection, and prevention of FWA in the PIHP Closed Provider Network. 2. Contact: appropriately qualified contact. Need not be compliance officer or contract manager. 3. Meetings & Minutes: Quarterly meetings with DMA PI and MFCU/MID. Redacted minutes if DMA asks. 4/21/

27 14.2 Fraud & Abuse: 42 CFR PIHP must have policies, procedures, system for 15 (overlapping) requirements. Prescriptive beyond reg. 1. Dedicated monitoring/auditing staff 2. Law enforcement coordination 3. Sharing documents/info with State 4. Detailed workflow: logging the complaint, determining if the complaint is valid, assigning the complaint, investigating, appeal, recoupment, and closure 5. Audits/Self-Audits/Investigations: 60-day provider return of overpayments; template form including collections 6. Data mining process 7. Educate on FCA 8. DMA-approved service-verification template 4/21/

28 14.2 Fraud & Abuse: PIHP-DMA Process 1. PIHP must start preliminary investigation w/i 10 b- days of receipt of potential allegation of fraud and forward info/evidence to DMA PI w/i 5 b-days of final determination allegation rises to potential fraud. 2. Details list required for provider/enrollee referrals 3. DMA & PIHP mutually agree on forms 4. PIHP must use DMA FAMS unless DMA approves alternative. If FAMS, must provide claims data and have 48 hours to notify DMA of FAMS-user termination or job change. 5. NCID holders/fams-users list due by midnight of 10 th of each month, and quarterly sample reviews 4/21/

29 14.3 Provider Payment Suspension/Overpayment 1. DMA PI to complete preliminary investigation w/i 30 b-days of PIHP referral 2. DMA PI to refer to MFCU/MID w/i 5 b-days of determining full investigation warranted 3. DMA to update PIHP monthly 4. DMA to temporarily suspend payments depending on MFCU/MID investigation impact. PIHP to comply w/ DMA payment suspension notice. 5. PIHP to provide info/personnel DMA needs for review/reconsideration 6. PIHP can still enforce contract, etc., to extent won t interfere with access to care or ongoing investigation by DMA, MFCU/MID or other oversight agency. 7. DMA must give prior written notice to PIHP of RAC provider audits. 8. Sharing/return to PIHP of MFCU/MID provider recoveries being worked out, to possibly include in rate setting. 4/21/

30 1. Official MMC Final Rule (5/6/16): /medicaid-and-childrens-health-insurance-programchip-programs-medicaid-managed-care-chip-delivered 2. MMC Technical Amendments (Dec. 2016): /medicaid-and-childrens-health-insurance-programchip-programs-medicaid-managed-care-chip-delivered 3. Nov CMS FAQs: Policy-Guidance/Downloads/FAQ pdf 4/21/

31 4. CMS Final Rule PowerPoint: 5. CMS 8/16 Info required on Web: 6. CMS Comprehensive Program Integrity Plan: Guidance/Legislation/DeficitReductionAct/Downloads/cmip2 014.pdf 4/21/

32 7. Kaiser Family Foundation (June 2016) MMC Final Rule Summary: Rule-on-Medicaid-Managed-Care 8. Update in Jan on pass-through payments: / /medicaid-program-the-use-of-new-orincreased-pass-through-payments-in-medicaidmanaged-care-delivery 4/21/

33 Questions? 4/21/