The Indiana Family and Social Services Administration Office of Medicaid Policy & Planning

Transcription

1 The Indiana Family and Social Services Administration Office of Medicaid Policy & Planning Indiana Health Coverage Programs Program Integrity (PI) 2017 Annual IHCP Provider Workshops James Waddick, Jr., MBA, CPC, CPIP OMPP PI SUR Audit Manager

2 Agenda Program Integrity Who is Program Integrity (PI)? Who else audits Indiana Medicaid? Voluntary Self Disclosure Update from PI Activities Questions / Contact Information

3 Contact Information Option 8 Only formal responses to questions asked through the inquiry process will be considered official and valid by the State. No participant shall rely upon, take any action, or make any decision based upon any verbal communication with any State employee including responses in today s presentation.

4 Who or What is Program Integrity? FSSA Program Integrity (PI) is composed of four (4) collaborative groups: Investigations & Coordination Prepayment Review Surveillance & Utilization Review (SUR) - Audit Estate Recovery

5 Who or What is Program Integrity? (con t.) Investigations & Coordination Respond to complaints from members, providers, other state agencies, etc. Conduct preliminary investigations to establish a Credible Allegation of Fraud (CAF) Collaborate with Medicaid Fraud Control Unit on provider investigations Coordinate with FSSA operating divisions (DDRS, DA, DMHA, DFR) to follow-up on issues Oversee the Managed Care Entities (MCE s) to monitor their Special Investigation Units and referrals of provider fraud allegations

6 Who or What is Program Integrity? (con t.) Prepayment Review Work designated to FADS contractor, Truven Health Analytics/ IBM Watson Health effective October 2017 All contact information and mailing locations remain the same. Any changes will be relayed to providers as needed. Typically result of potential concerns with provider billing or documentation practices Provider submission of supporting documentation with claims Must meet 85% accuracy rate in claims submission for three (3) consecutive months within the initial six (6) month review period

7 Who or What is Program Integrity? (con t.) Surveillance & Utilization Review (SUR) - Audit Retrospective review of provider billing compliance Review of both Fee-for-Service & Managed Care Utilize provider peer comparison to identify outliers from peers Audit Approach Algorithms vs. provider-specific Can utilize statistically-valid, random-sampling & extrapolation Recovery of overpayments Federal share of all Medicaid recoveries must be repaid to CMS within 365 days of overpayment notification

8 Who or What is Program Integrity? (con t.) Estate Recovery Medicaid uses taxpayer money to help pay for medical services for qualified individuals When a Medicaid recipient dies, the State of Indiana is required by both federal and state law to seek recovery of the Medicaid funds that were used to pay for those medical services FSSA will seek recovery from a recipient s estate for the total amount of Medicaid paid on behalf of the recipient after they turned fifty-five (55) years of age An estate recovery debt is due upon the recipient s death 1.) when the recipient was age 55; or 2.) when the recipient was under age 55 and a resident of a long term care facility, who cannot be reasonably be expected to be discharged and returned to the individual s home. estaterecovery@fssa.in.gov Phone:

9 Indiana Medicaid Program Integrity Audit Process Why must we audit? PI SUR conducts retrospective reviews of Indiana Medicaid providers to evaluate and document patterns of healthcare provided to recipients, as well as ensure compliance with Indiana Medicaid, applicable federal & coding guidelines, and recover any overpayments. This is facilitated through our Fraud & Abuse Detection System (FADS) contractors Statewide surveillance and utilization control program. The Medicaid agency must implement a statewide surveillance and utilization control program that - (a) Safeguards against unnecessary or inappropriate use of Medicaid services and against excess payments

10 Retrospective Audit Process Steps involved in PI retrospective review process: 1. Preliminary review of provider history and investigation determine next steps 2. Request of medical records from IN Medicaid provider 3. Medical record/on-site audit 4. Draft Audit Findings (DAF) letter of preliminary audit results * 5. Administrative Reconsideration Process 6. Final Calculation of Overpayment (FCO) letter 7. Administrative Appeal 8. Repayment of Overpayment

11 Who else may audit Indiana Medicaid? Reviews can be initiated by other external entities in conjunction with IN Program Integrity, including, but not limited to: CMS Payment Error Rate Measurement (PERM) audit 3-year cycle current cycle started mid-2016 Establish state-wide error rate from sample audit Chicksaw Nation Industries (CNI) and The Lewin Group (vendors) Please direct any questions you may have to or (317)

12 Who else may audit Indiana Medicaid? (con t.) CMS (con t) Unified Program Integrity Contractor (UPIC) CMS-directed audit contractor to assist State PI efforts CMS approves audits Indiana UPIC vendor = NCI AdvanceMed Recovery Audit Contractor (RAC) Indiana contractor HMS Focused on credit-balance audits & reviews of LTC providers

13 Who else may audit Indiana Medicaid? (con t.) Department of Health & Human Services Office of Inspector General Issue-specific reviews (ie. code billed; drug dispensed; service ordered) Contact State PI to pull claims data to review Findings of issue directed to State Medicaid program to pursue recovery and develop a Corrective Action Plan (CAP), if warranted Recent examples: Indiana Made Incorrect Medicaid Payments to Providers for Full Vials of Herceptin Indiana Claimed Medicaid Reimbursement for High-Dollar Inpatient Services That Were Unallowable State PI works to validate audit results, then utilize standard State process to recover overpayments

14 Who else may audit Indiana Medicaid? (con t.) Indiana Medicaid Fraud Control Unit (MFCU) Fraud is an intentional deception or misrepresentation, made by the provider or member, which could result in an unauthorized benefit, such as an improper payment being made to an IHCP provider. The following list contains examples of fraud: Altering a member s medical records to generate fraudulent payments Billing for group visits, such as a provider billing for several members of the same family in one visit, although only one family member was seen or provided medically necessary services Billing for services or supplies that were not rendered or provided Misrepresenting services provided (for example, billing a covered procedure code and providing a non-covered service) Soliciting, offering, or receiving a kickback, bribe, or rebate Submitting claim forms that have been altered or manipulated to obtain higher reimbursement

15 Provider Voluntary Self-Disclosure Mandatory reporting 42 U.S.C. 1320a-7k(d) Provider Self-Disclosure packet located on the State PI website

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17 42 U.S.C. 1320a-7k(d) (d) Reporting and Returning of Overpayments (1) in general, - If a person has received an overpayment, the person shall - A.) Report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and B.) Notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.

18 Report and Return to Correct Address Standardized tool for reporting overpayments Notify with reason for overpayment In Indiana, overpayments should be returned, reported and explained to the PI Unit at the following address: IHCP Program Integrity Department ATTN: SUR Audit Overpayment P. O. Box Cincinnati, OH

19 42 U.S.C. 1320a-7k(d) (2) Deadline for reporting and returning overpayments. - An overpayment must be reported and returned under paragraph (1) by the later of - A.) The date which is 60 days after the date on which the overpayment was identified; or B.) The date any corresponding cost report is due, if applicable.

20 Additional Benefit of Provider Voluntary Self-disclosure 405 IAC Overpayments made to providers; recovery Authority: IC ; IC ; IC Affected: IC ; IC ; IC ; IC ; IC (g) Whenever the office determines, after an investigation or audit, that an overpayment to a provider should be recovered, the office shall assess an interest charge in addition to the amount of overpayment demanded. Such interest charge shall not exceed the percentage set out in IC (e)(1) [IC was repealed by P.L , SECTION 270, effective July 1, 2011.]. Such interest charge shall be applied to the total amount of the overpayment, less any subsequent repayments. Under IC (6), the interest shall: (1) accrue from the date of the overpayment to the provider; and (2) apply to the net outstanding overpayment during the periods in which such overpayment exists. In instances of provider self-disclosure, interest is not assessed on the disclosed overpayment amount.

21 Federal Exclusions Excluded Individuals The Online Searchable Databases enable users to enter the name of an individual or entity and determine whether they are currently excluded. If a name match is made, the database can verify the match using a Social Security Number or Employer Identification Number. Any claims involving excluded individuals or business will be recouped in full as overpayments Also refer to IHCP Provider Bulletin BT (Federal Health Care Exclusions Program)

22 False Claims and Whistleblower Regulations Indiana enacted State False Claim and Whistleblower statute: Indiana Code Federal False Claims Act: 31 USC Report Medicaid Fraud to Attorney General: False Claims and Whistleblower education:

23 Avoiding Billing Errors OMPP PI works with IN Fraud and Abuse Detection System (FADS) contractors to identify potential billing problems Select billing issues related to claims processing glitches no interest assessed on overpayments Typical billing errors noted in SUR audits: Missing documentation of service duration time on services that are time-based. Missing patient identification information on documentation. Incorrect coding of services. Missing or insufficient documentation to support service billed. Unbundling of services. Copied or cloned notes. Overlapping of services during the same block of time. Billing for non-covered services with covered service code.

24 Contact Information Only formal responses to questions asked through the inquiry process will be considered official and valid by the State. No participant shall rely upon, take any action, or make any decision based upon any verbal communication with any State employee including responses in today s presentation.

25 THANK YOU!