Jennifer Putt, CFE Manager of Program Integrity August 12, VBH-PA Provider Self-Audit Protocol

Transcription

1 VBH-PA Provider Self-Audit Protocol Jennifer Putt, CFE Manager of Program Integrity August 12,

2 Topics for Today s Presentation Background and Requirements for Provider Self- Audits Examples of Inappropriate Payments Suitable for Provider Self-Audits Types of Provider Self-Audits 2

3 Background and Requirements for Provider Self-Audits 3

4 Background and Requirements for Provider Self-Audits Federal Requirements: OIG Department of Health and Human Services: Self- Disclosure Protocol: Provider Self-Disclosure HHS Contractors and Self-Disclosures HHS Grantee Self-Disclosure Self-disclosure can reduce the civil penalties and corrective actions that can be imposed for overpayments 4

5 Background and Requirements for Provider Self-Audits OIG Provider Self-Disclosure OIG self-audit protocol introduced in 1998 Process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud OIG emphasizes that the health care industry has a legal and ethical duty to report overpayment and potential fraud, which includes the following obligations: Taking measures to detect and prevent fraudulent and abusive activities Implementing specific procedures and mechanisms to investigate fraud Resolving and correcting to prevent future instances of potential fraud 5

6 Background and Requirements for Provider Self-Audits OIG Provider Self-Disclosure Benefits of good faith disclosures and cooperation with the OIG: Provides evidence of a robust compliance program Allows for integrity agreements instead of exclusion Allows for lower multiplier and single damages Prevents suspension of future payments Reduces OIG investigations 6

7 Background and Requirements for Provider Self-Audits Pennsylvania Requirements Medical Assistance Bulletin , The Bureau of Program Integrity and the Medical Assistance Provider Self-Audit Protocol: Requires all providers to conduct self-audits and return overpayments in accordance with the protocol Requires all Managed Care Organizations to have provider self-audit protocols and processes for HealthChoices ulletin_admin/d_ pdf 7

8 Background and Requirements for Provider Self-Audits Medical Assistance Bulletin BPI suggests that providers consider the following recommendations to ensure compliance with MA regulations and avoid possible sanctions and penalties: Providers should be aware of billing requirements and compensable services under the MA Program. Providers, to the extent practicable, should adopt and implement compliance plans to ensure that they remain in compliance with MA regulations. As part of a compliance plan, providers should periodically conduct self-audits to ensure compliance with MA regulations. To the extent that overpayments are identified, providers should utilize the MA Provider Self-Audit Protocol to facilitate the return of overpayments. 8

9 Background and Requirements for Provider Self-Audits Medical Assistance Bulletin BPI can take the following actions for providers that do not identify and return overpayments: Educational and training letters; Recover improperly paid funds; Terminate a provider s provider agreement and preclude a provider s direct and indirect participation in the MA Program; Refer the case to the Attorney General s MFCU or other appropriate criminal law enforcement agency; Refer a case to an appropriate civil agency Seek a civil monetary penalty amounting to twice the overpaid amount plus interest; or Recommend internal policy changes to improve and/or clarify program standards. 9

10 Background and Requirements for Provider Self-Audits Medical Assistance Bulletin BPI states that providers will receive the following benefits from self-disclosure: DHS will not seek double (or triple) damages, but will accept repayment without penalty if self-audits are voluntary and identified by provider prior to an oversight audit DHS can provide assistance and training during the selfaudit processes 10

11 Background and Requirements for Provider Self-Audits Medical Assistance Bulletin BPI states that MCOs should have self-audit protocols for providers: MCOs are required to have a provider self-audit protocol MCOs are required to educate providers on self-audits MCOs should work collaboratively with BPI and DHS on provider self-audits 11

12 Background and Requirements for Provider Self-Audits Pennsylvania Requirements PA Department of Human Services (DHS) Bureau of Program Integrity (BPI) Information on provider selfaudit protocols: Provides options for conducting self-audits directly with DHS and BPI VBH-PA has a similar provider self-audit protocol for HealthChoices services and members calassistanceproviderselfauditprotocol/ 12

13 Examples of Inappropriate Payments Suitable for Provider Self- Audits 13

14 Fraud, Waste, and Abuse Fraud must be reported and will result in overpayments that providers need to return Fraud can result in civil and criminal penalties Fraud may be identified through self-audits Fraud: Any intentional deception or misrepresentation made by an entity or person in a capitated MCO, Primary Care Case Management (PCCM), or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting 14

15 Fraud, Waste, and Abuse Providers must return overpayments from abuse and waste within 60 days or the overpayments held can be considered fraud Abuse: Any practices in a capitated MCO, Primary Care Case Management (PCCM) program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting Waste: Thoughtless or careless expenditure, consumption, mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls 15

16 Fraud, Waste, and Abuse Fraud, waste, and abuse that can result in provider overpayments: Any services that are out of compliance with PA or Federal Code Any services that are out of compliance with PA Medical Assistance Payment Regulations Any services that do not meet the VBH-PA Provider Manual requirements or minimum documentation standards Any services that are not within the scope of practice standards or service descriptions 16

17 Examples of Inappropriate Payments Suitable for Provider Self-Audits A psychiatric inpatient hospital provider bills and received payment for primary Drug and Alcohol services not payable to a psychiatric hospital or hospital psychiatric unit A provider bills MA with an incorrect prescriber s or practitioner s license number A mental health outpatient clinic determines that psychotherapy groups had more than 10 participants, when payment regulations require psychotherapy groups to be for 2 to 10 members for at least a continuous 60 minutes 17

18 Examples of Inappropriate Payments Suitable for Provider Self-Audits A family based mental health services or behavioral rehabilitation provider discovers that clinicians are billing for travel or no shows A psychiatric partial hospitalization program bills for time spent transporting the client to and/or from the partial program or for time spent in activities away from the licensed site 18

19 Examples of Inappropriate Payments Suitable for Provider Self-Audits Two or more physicians involved in rendering an inpatient service bills different procedure codes for the same service A methadone maintenance provider bills for services provided prior to the clinic supervisory physician s examination/evaluation and/or treatment plan A psychiatric outpatient clinic bills for a medication administration visit when no medication was administered 19

20 Types of Provider Self-Audits 20

21 Types of Provider Self-Audits Self-Audit and Adjustments for Errors without Patterns Individual Claims Adjustments: Documentation errors and overpayments that are limited to a specific occurrence through standard monitoring and auditing Errors have no patterns and are not repetitive Error rate is below a pre-determined threshold Example: During a quarterly review of 25 member records, a provider discovers the following: 23 member records have no errors,1 member record has incomplete treatment plan review, and 1 member record is missing a progress note Through the self-audit process, the provider will request specific claims adjustments for the claims associated with the incomplete treatment plan and the claim for the missing progress note 21

22 Types of Provider Self-Audits Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences 100% Review of Claims: Documentation errors and overpayments are repetitive and consistent through the review Error rate is above a pre-determined threshold Case-by-case review of claims is administratively feasible and costeffective Example: During a quarterly review of 25 member records, a provider discovers the following: 20 member records have no findings and 5 member records has missing encounter forms for various dates of service The provider determines the missing encounter forms are from a new clinician that has only been providing service for 6 months The provider decides to review 100% of the new clinician s claims to determine the error rate of missing encounter forms to calculate the correct overpayment and implement corrective actions 22

23 Types of Provider Self-Audits Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences Provider-Developed Self-Audit Work Plan: Documentation errors and overpayments are repetitive and consistent through the review Case-by-case review of claims is NOT administratively feasible and cost-effective The provider must project the actual error rate and overpayments Example: During an on-site CMS review of 100 claims, CMS discovers the following: 60 claims have no findings and 40 claims were for group services that had more than 10 participants The provider determines a case-by-case review of claims is NOT administratively feasible and cost-effective because there are 10,000 claims that require member record reviews The provider decides to submit a plan to use CMS error rate and extrapolation to calculate overpayments and implement corrective actions 23

24 VBH-PA Provider Self-Audit Protocol VBH-PA Provider Self-Audit Protoc ol 24

25 The provides detailed instructions and is available at the following: Protocol.pdf VBH-PA allows providers to select the methodology of self-audit based on the types of self-audits: Self-Audit and Adjustments for Errors without Patterns Individual Claims Adjustments Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences 100% Review of Claims Provider-Developed Self-Audit Work Plan 25

26 The provides instructions on how to use each of the forms available online: Attachment #1: VBH-PA Claims Spreadsheet Attachment #2: VBH-PA Provider Self-Audit Referral Form Attachment #3: VBH-PA Provider Audit Response Attachment #4: VBH-PA Provider Self-Audit Work Plan Form 26

27 Additional Tips for the VBH-PA Provider Self-Audit Protocol: All information related to self-audits should be sent to the following If you do not have encrypted , you must contact the above before sending member information A VBH-PA Program Integrity Auditor will be assigned to each provider self-audit and will assist the provider through the steps of the protocol Please visit the VBH-PA Program Integrity Contact Information on Fraud and Abuse webpage 27

28 Review of VBH-PA Provider Self- Audit Protocol Giving Value Back to the Provider

29 Review Documents on VBH-PA Webpage 29

30 Questions? 30

31 Thank you 31