Kristina Denton, BA, QP, CI Special Investigations Unit Program Integrity Specialist April 18 th 2017, 10:00 1:00 Lumberton

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1 Kristina Denton, BA, QP, CI Special Investigations Unit Program Integrity Specialist April 18 th 2017, 10:00 1:00 Lumberton April 20 th 2017, 10:00 1:00 Rocky Mount

2 Define Fraud, Waste and Abuse Identify how much is paid annually in improper payments Identify laws, rules and regulations authorizing & requiring program integrity reviews Learn reasons for an audit Learn what to expect from PI during an audit Learn what is expected and required of you as a provider during an audit Learn what a self-audit is and how to complete Learn about pre-payment reviews Learn what happens after an audit is completed

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4 An improper payment is any payment that should not have been made or that was made in an incorrect amount under statutory, contractual, administrative, or other legally applicable requirements. Incorrect amounts include overpayments and underpayments. An improper payment includes any payment that was made to an ineligible recipient, payment for non-covered services, duplicate payments, payments for services not received, and payments that are for the incorrect amount. In addition, when an Agency s review is unable to discern whether a payment was proper because of insufficient or lack of documentation, this payment must also be considered an improper payment.

5 Improper Payments divert resources away from necessary care, may subject health care professionals to recoupment, and If the result of fraud or abuse, may also incur criminal penalties and other sanctions. Waste and Abuse are not considered criminal offenses according to CMS however can result in your agency being placed on suspension by DMA, your contract terminated by an MCO and/or recovery of improper payments, fees, restitution and other administrative and civil penalties.

6 Government Accountability Office, Fundamental Improvements Needed in CMS's Effort to Recover Substantial Amounts of Improper Payments, April 8, 2016.

7 FISCAL REPORTING YEAR IMPROPER AMOUNT (IN BILLIONS) IMPROPER RATE 2009 $ % 2010 $ % 2011 $ % 2012 $ % 2013 $ % 2014 $ % 2015 $ % 2016* $38.9* 11.5% 2017* $38.3* 10.5% 2018* $26.8* 7.4% GOA Financial Audit *Projected Payments

8 The FWA continuum is predicated on intent to deceive, meaning the more intentionally deceptive a practice is, the more likely it is to be deemed fraudulent. The Centers for Medicare and Medicaid Services (CMS ) definition of FWA is illustrated in this continuum: Errors Waste Abuse Fraud Mistakes such as Incorrect Coding or other Administrative Mistakes. Inefficiencies such as habitually using incorrect codes or duplicate billing. Bending the Rules such as Upcoding or Over-utilizing services. Intentional Deception such as knowingly billing for services or products not rendered.

9 Waste, according to Centers for Medicare and Medicaid Services (CMS), is the result of honest mistakes and human errors. Waste implies no malicious intent. But, as the term suggests, spending is inefficient and costly. CMS Medicare Learning Network: Medicare Fraud & Abuse Prevention, Detection, and Reporting, August 2014

10 Abuse describes practices that, either directly or indirectly, result in unnecessary costs to the Medicaid Program. Abuse includes any practice that is not consistent with the goals of providing patients with services that are medically necessary, meet professionally recognized standards, and priced fairly. CMS Medicare Learning Network: Medicare Fraud & Abuse Prevention, Detection, and Reporting, August 2014

11 Knowingly submitting false statements or making misrepresentations of fact to obtain a federal health care payment for which no entitlement would otherwise exist; Knowingly soliciting, paying, and/or accepting remuneration to induce or reward referrals for items or services reimbursed by Federal health care programs; or Making prohibited referrals for certain designated health services CMS Medicare Learning Network: Medicare Fraud & Abuse Prevention, Detection, and Reporting, August 2014

12 Fraud Medical identity theft (using another licensed professional s NPI); Kickbacks (offering, soliciting, paying, or receiving remuneration (in kind or in cash) to induce, or in return for referral of patients or the generation of business involving ANY item or service paid by a federal health care program) Kickbacks in health care can lead to overutilization, increased program costs, corruption of medical decision-making, patient steering, and unfair competition; Beneficiary fraud (using someone else Medicaid card, hiding or lying about resources to qualify for Medicaid); Billing for non-covered services or items (i.e. mentoring, misrepresenting symptoms or falsifying a diagnosis in the patient s medical record and performing unnecessary procedures); Billing for services not provided (i.e. purchasing or obtaining medicaid IDs and billing without consent, billing more often then the patient is physically seen for services, billing for medical equipment never received); Misrepresenting dates of service (ex. Billing for two services that occurred on the same date but policy excludes so you bill on two separate dates); Misrepresenting provider of a service (i.e. billing for an LP when a QP provided the service Ex. Provider bills for a CCA when a QP completes an admission assessment); Double-Billing or Double Dipping (billing more than one insurance for same service or billing one insurer twice)

13 Abuse Over-utilization (Billing for unnecessary services or items or more than what s needed); Upcoding (billing for services at a level of complexity higher than the service actually provided or documented, ex. billing for individual therapy when group was provided); Unbundling (practice of submitting bills in a fragmented fashion in order to maximize the reimbursement, ex. billing for both individual or family therapy AND Intensive In-Home without EPSDT approval); Misusing policies ( ex. billing SAIOP and SACOT repeatedly under pass-through; providing parts of a service instead of meeting all requirements)

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15 United State Code of Federal Regulations 42 CFR Section (a)administrative and management arrangements or procedures to detect and prevent fraud, waste and abuse. The State, through its contract with the MCO, PIHP or PAHP, must require that the MCO, PIHP, or PAHP, or subcontractor to the extent that the subcontractor is delegated responsibility by the MCO, PIHP, or PAHP for coverage of services and payment of claims under the contract between the State and the MCO, PIHP, or PAHP, implement and maintain arrangements or procedures that are designed to detect and prevent fraud, waste, and abuse.

16 42 CFR Section Preliminary investigation. If the agency receives a complaint of Medicaid fraud or abuse from any source or identifies any questionable practices, it must conduct a preliminary investigation to determine whether there is sufficient basis to warrant a full investigation.

17 42 CFR Section State plan requirements. (a) A State plan must provide that the requirements of this part are met; (b) These requirements may be met by the agency by: (1) Assuming direct responsibility for assuring that the requirements of this part are met; or (2) Deeming of medical and utilization review requirements if the agency contracts with a QIO to perform that review, which in the case of inpatient acute care review will also serve as the initial determination for QIO medical necessity and appropriateness review for patients who are dually entitled to benefits under Medicare and Medicaid; (c) In accordance with of this subchapter, FFP will be available for expenses incurred in meeting the requirements of this part.

18 NC General Statutes Chapter 108C 108C-11. Cooperation with investigations and audits. (a) Providers shall cooperate with all announced and unannounced site visits, audits, investigations, post-payment reviews, or other program integrity activities conducted by the Department. Providers who fail to grant prompt and reasonable access or who fail to timely provide specifically designated documentation to the Department may be terminated from the North Carolina Medicaid or North Carolina Health Choice programs.

19 108C-7. Prepayment claims review. (a) In order to ensure that claims presented by a provider for payment by the Department meet the requirements of federal and State laws and regulations and medical necessity criteria, a provider may be required to undergo prepayment claims review by the Department. Grounds for being placed on prepayment claims review shall include, but shall not be limited to, receipt by the Department of credible allegations of fraud, identification of aberrant billing practices as a result of investigations or data analysis performed by the Department or other grounds as defined by the Department in rule.

20 Your NC DHHS Participation Agreement l. That all claims are subject to the North Carolina False Claims Act, Chapter 1, Article 51 of the North Carolina General Statutes (N.C.G.S through 617), the federal False Claims Act, and when applicable the Medical Assistance Provider False Claims Act (Part 7, Article 2, Chapter 108A of the General Statutes). Your Contract with the MCO 5. FRAUD, ABUSE, OVER UTILIZATION AND FINAL OVERPAYMENTS, ASSESSMENTS OR FINES: a. CONTRACTOR understands that whenever LME/PIHP receives a credible allegation of fraud, abuse, overutilization or questionable billing practice(s), the LME/PIHP is required to provide the Division of Medical Assistance with the provider name, type of provider, source of the complaint, and approximate dollars involved.

21 An audit, investigation, post-payment review, monitoring or any other activity designed to ensure the integrity of the Medicaid and IPRS programs or to determine whether a provider or recipient has engaged in fraud, waste, abuse, overutilization, error or any other aberrant practices, or the billing of medically unnecessary services.

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23 Eastpointe shall conduct post-payment reviews as a part of Provider monitoring reviews, special investigations and just cause audits. An allegation was submitted to Eastpointe regarding your staff or agency. Remember: Anyone, at Any Time can make Any Allegation. MCO s and DMA are required by federal, state and local statutes to investigate ALL allegations.

24 Allegations come in through various sources, some of which are: Members or family of members Other providers Data Analytics firms/agencies Internal concerns (UM, STR, CC, NO, etc.) Other MCO s DMA Law Enforcement DSS

25 Again, MCO s and DMA are required to investigate ALL allegations no matter how many times the provider has been audited previously or what the findings were. EVEN if it s the same allegation or from the same complainant. EVERY allegation MUST be investigated. Even if you have gone through a recent review by Provider Monitoring and had no negative findings, PI must still investigate. Each department focuses on different issues.

26 Provider Monitoring focuses on compliance issues such required elements of documentation, clinical policy requirements, and personnel requirements. Program Integrity focuses on fraud, waste and abuse.

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28 As stated earlier, MCO s are required by contract with DMA, federal and state regulations and laws to conduct Program Integrity Audits. All allegations must receive a preliminary review within 10 business days of receipt.

29 All allegations coming into Eastpointe Program Integrity are presented to the PI department following the preliminary review. If the allegation is determined to be potential fraud, waste or abuse it is then evaluated and given a risk assessment score.

30 If the allegation is NOT determined to be potential fraud, waste or abuse it is referred to the appropriate internal department for review. At times, multiple allegations come into Eastpointe. These allegations, if possible, are combined into one investigation to reduce the hardship on the provider and reduce waste of PI resources.

31 Program Integrity Behavioral Healthcare Audit (Most Common) A PI Audit is a review of claims following payment. This is the most common type of review and a sample of members and claims are selected based on the allegations, services involved, number of members served and overall number of claims billed. Any overpayments identified by this review may be recouped or collected. Reviews involve examination of claims, payment data, medical record documentation, financial records, administrative research, application of Medicaid coverage policies, and any additional information to support Provider s operation and processes. An audit may be conducted on-site or through desk review.

32 Pre-Payment Review A pre-payment review is a review of claims as they are submitted for payment. Payment will not be made until supporting documentation is received, reviewed and approved by MCO staff.

33 Voluntary Self-Audit A voluntary self-audit is an audit that you as the provider conduct yourself. You can submit the results to the MCO for review however it is not required unless you have findings of overpayment. Eastpointe reserves the right to validate all outcomes and repayments.

34 Involuntary Self-Audit An involuntary self-audit is an audit conducted by the provider that has been required by the MCO. This typically follows an investigation and all results must submitted upon completion.

35 Program Integrity Audit What to Expect and What is Expected: All Program Integrity Audits are Unannounced, No Exceptions. At no time can PI divulge the specifics of the allegation(s) or who made it. A minimum of two MCO Program Integrity staff will be present during the review. There is no limit on the number of members we can review however, the sample size is guided by the allegations and your operations (size, services, etc.).

36 We will need a space that is as private (from members and guests) as possible and large enough to accommodate 2 to 4 PI staff and equipment with access to electrical outlets. We understand some smaller providers do not have this space, we will work with you as best we can. You will receive a written notice upon arrival of intent to review records and claims. You will also received an itemized list of requested items. You will be provided a final submission time that takes into account what is being requested and your operating hours. Eastpointe staff must exit your site by your posted closing time.

37 All providers shall provide all documents requested and be cooperative throughout the review. Not providing requested items and/or interfering with an investigation are causes for automatic recoupment and/or suspension or termination of your contract, see Section 13, item vi. Unless otherwise instructed, you should bring the entire clinical and/or personnel record to PI staff for review. Specific items requested will be scanned and refiled unless the provider asks us not to refile. At times, we may need copies made. If this occurs, PI staff will provide copy paper.

38 Once all requested items are received and scanned PI staff will conduct an exit interview. This interview may consist of interview questions for staff available. PI staff will review and provide you a copy of completed forms identifying all items received/not received.

39 Program Integrity Audit What to Expect and What is Expected: A desk review is completed the same as an on-site review, except how the provider is notified and provides requested items to the MCO. During a Desk Review, the MCO will mail, or fax a notice of intent to review records and claims along with an itemized list of requested items. The provider will be given 10 business days to provide all requested documents. Desk Reviews are typically reserved for investigations where the allegations have been deemed insignificant or minor. It could also be based on type of allegation, agency size, number of agency sites involved, or other factors that may impact the investigation.

40 A provider is typically placed on pre-payment review when provider history indicates a systemic or programmatic problem that results in frequent overpayments however, according to GS 108C-7 a provider may be placed on prepayment claims review for grounds that shall include, but shall not be limited to, receipt by the Department of credible allegations of fraud, identification of aberrant billing practices as a result of investigations or data analysis performed by the Department or other grounds as defined by the Department in rule. Eastpointe shall review 100% of the provider s claims for a minimum of three (3) consecutive months to ensure that the claims comply with controlling authority.

41 A provider on pre-payment review MUST achieve a minimum of 70% clean claims rate for a minimum of 3 consecutive months before they can be released from prepayment. For purposes of determining when a provider achieves the minimum 70% clean claims rate pursuant to G.S. 108C-7, the following shall apply: a. Any services provided during the period the provider is on prepayment claims review shall be reviewed and included in the clean claims rate, regardless of the date the claim is submitted for billing; and b. When no claims are submitted during a month when the provider is on prepayment claims review, the clean claims rate shall be calculated as zero percent (0%) for the month.

42 When submitting claims subject to the prepayment claims review process, a provider shall submit the requested records pursuant to G.S. 108C-7(b) on the same day that a claim is submitted for payment with Eastpointe. If the provider fails to provide any of the requested records, Eastpointe shall notify the provider of the deficiency. If the requested records are not submitted within twenty-four (24) clock hours from the date of the notice, the claim(s) associated with the records request shall be denied. The records submitted will be reviewed by Eastpointe staff. If determined to be in compliance with Medicaid and State funded Clinical Coverage policies according to State Plan, Waiver, and Prepaid Inpatient Health Plan the claim will be paid. If the provider fails to comply with any of the requirements of the prepayment review(s), the provider may be subject to additional sanctions determined by Eastpointe.

43 Voluntary self-audits should be a standard part of your agencies compliance (QA/QI) plan. Self-audits are a valuable tool providers can utilize to ensure compliance. Reminder: Providers that receive annual payments under the State Plan of at least $5,000,000, as a condition shall establish written policies for all employees of the entity (including management), and of any contractor or agent of the entity, that provide detailed information about the False Claims Act established under sections 3729 through 3733 of title 31, United States Code, administrative remedies for false claims and statements established under chapter 38 of title 31, United States Code, any State laws pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws, with respect to the role of such laws in preventing and detecting fraud, waste, and abuse in Federal health care programs (as defined in section 1128B(f)); include as part of such written policies, detailed provisions for detecting and preventing fraud, waste, and abuse; and include in any employee handbook for the entity, a specific discussion of the laws described in subparagraph (A), the rights of employees to be protected as whistleblowers, and the entity s policies and procedures for detecting and preventing fraud, waste, and abuse.

44 The provider shall maintain all documentation and records related to a self-audit. The provider shall maintain all audit findings. Eastpointe may request copies of audit(s) documentation. The provider shall provide to Eastpointe with fifteen (15) calendar days of request, copies of the self-audit, audit findings, and all documentation supporting the audit findings. Upon review of information submitted by the provider or upon further investigation, Eastpointe shall refer all allegations of Provider Medicaid fraud, waste or abuse to DMA. Self-Audit instructions, requirements and submission guidelines along with forms are found on Eastpointe s website at under Home/Provider/Information, Manuals and Forms/Forms/Program Integrity.

45 In accordance with G.S. 108c-5, voluntary selfaudits are completed by the provider as scheduled or random reviews of member and personnel records to ensure compliance with local, state and federal rules. Eastpointe reserves the right to validate all provider self-audit outcomes and repayments. If errors are identified, the provider may be subject to sanctions.

46 Involuntary self-audits are completed the same way voluntary audits are completed but the requirement to complete such an audit is issued by the MCO. If a provider is required to complete a self-audit, the provider will receive a written Self-Audit Notice via certified mail. Involuntary self-audits may be issued when the following occur but not limited to: an allegation has been received and following a preliminary review it is determined a provider self-audit is warranted; or a provider has been investigated and trends of fraud, waste or abuse are not discovered for the selected sample time frame however, other compliance issues are found. The provider may be required to complete a self-audit to review those issues in an expanded time frame and/or member/personnel sample.

47 Upon receipt of a provider s self-audit and supporting documentation, Eastpointe will either approve or not approve the findings. Eastpointe reserves the right to validate all provider self-audit outcomes. If the findings are approved and no errors are identified, no further actions are required. If the findings are approved and errors are identified, Eastpointe will move forward with recouping or collecting any overpayments or issuing other sanctions as indicated. If the findings are incomplete or not accepted, Eastpointe may elect to conduct further investigation and will refer all allegations of fraud, waste or abuse to DMA.

48 Prepare and send the following documents to Eastpointe Program Integrity Department A. Cover letter on your business letterhead that summarizes: overview of the issues identified time period covered by the review (evaluate the problem for the full time period for which it occurred) type of sampling (100%, random, etc.) error percentage rate B. Self-Audit Invoice for Audit Findings C. Provider Refund Attachment D. Copy of the refund check (if applicable) or Copy of Electronic Submission of payment

49 Prepare and send the following documents to Eastpointe Business Office A. Refund check (if applicable) or Electronically Submit payment via (follow directions in the Eastpointe Claims Manual) B. Self-Audit Invoice for Audit Findings C. Provider Refund Attachment D. Copy of the cover letter that summarizes: overview of the issues identified time period covered by the review (please evaluate the problem for the full time period for which it occurred) type of sampling (100%, random, etc.) error percentage rate

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52 PI staff will complete a careful review of all items received during on-site, desk review or self-audit and determine findings. The PI team assigned along with the Director will make a determination of findings and recommendations to an independent committee.

53 If the findings indicate trends of potential Fraud, MCO s are required by contract with DMA and federal regulations to report the findings to DMA for further review. If the findings indicate trends of waste or abuse, the MCO can refer to DMA or take internal administrative action to include but not limited to recovery of overpayments, place the provider on pre-payment status, issue an involuntary self-audit, and/or suspend or terminate the provider s contract. If there are no findings of fraud, waste or abuse but there are other compliance issues Eastpointe may seek recovery of overpayment, issue an involuntary self-audit, and/or refer to other internal department for review. If the findings are against a licensed staff or facility, the MCO may report findings to any licensing boards or DHSR as applicable. The MCO may require the provider to take this action if warranted. If there are no findings of fraud, waste, abuse or other compliance issue the case will be closed with Eastpointe.

54 Upon completion of the review, the individual identified in your agency s contract as the Contract Administrator (identified in section 12) or the designated contact person will receive an outcomes letter. This letter will inform you the findings and any actions being taken. If administrative action is taken against your agency (payback, contract review, etc.), you will have appeal rights. If it is referred to DMA or another department with no other administrative actions, no appeal rights are available because no action is being taken at that time.

55 Are your records maintained according to applicable rules? How are your staff held accountable for compliance? How often do your complete random or scheduled reviews of both your client and staff records? Have you read your contract with Eastpointe? Do you attend the Provider Meetings? How often do you attend Program Integrity trainings? How is the information conveyed to your staff, owners, stakeholders? Would you report another provider, your staff, or your employer if you suspected them of committing fraud, waste or abuse?

56 Eastpointe MCO Website: (Provider/Program Integrity/Program Integrity Referral Form) Telephone: US DHHS: (1-800-HHS-TIPS) NC DMA/Medicaid Fraud, Waste and Program Abuse Tip-Line: 877-DMA-TIP1 ( ) NC DMA Online Form: (Get Involved Report Fraud, Waste or Abuse Scroll Down to Reporting Options Online Confidential Complaint Form)

57 Reporting can be anonymous. Even if you provide your name, it will not be released to the provider being investigated. Provide as many details as possible. If appropriate, include date(s) of service, Medicaid recipient names(s), Medicaid ID numbers(s), and recipient date(s) of birth. Please describe the specific Medicaid service involved. Upload supporting documents. For example, service grids or timesheets that show services were billed that weren t actually provided. Make sure ALL documentation provided to Eastpointe is for Eastpointe members ONLY. If documentation has any other member s information not necessary to share or not an Eastpointe member, redact (black out) all identifiable information. Be conscientious of HIPAA regulations. Use Safe Harbor guidelines found in HIPAA Privacy Rule (b)(2)(i).

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59 Program Integrity: Fraud, Waste & Abuse Toolkit - Healthcare Fraud and Program Integrity Education/fwa.html Healthcare Fraud and Program Integrity: An Overview for Providers Program Integrity: Self-Audit Toolkit Coordination/Fraud-Prevention/Medicaid-Integrity-Education/audit-toolkit.html Program Integrity: Behavioral Health Toolkit Coordination/Fraud-Prevention/Medicaid-Integrity-Education/behavioral-health.html Program Integrity: Documentation Matters Toolkit Coordination/Fraud-Prevention/Medicaid-Integrity-Education/documentation-matters.html Program Integrity: Electronic Health Records Coordination/Fraud-Prevention/Medicaid-Integrity-Education/electronic-health-records.html Medicaid Integrity Program - General Information Coordination/Fraud-Prevention/MedicaidIntegrityProgram/index.html Fraud Waste and Abuse Fact Sheet Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/fwa-factsheet.pdf

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