Effective Collaboration Between Compliance Officers and State and Federal Law Enforcement Elizabeth Lepic, Chief Counsel Illinois State Police Medicaid Fraud Control Unit Ryan Lipinski, CountyCare Compliance Officer Cook County Health & Hospitals System Kathleen McGinty, Chief Counsel & Deputy Inspector General Illinois Department of Healthcare & Family Services, Office of the Inspector General 1 OBJECTIVES 1. Learn effective strategies and best practices for collaboration between your Managed Care Compliance team, State Medicaid Inspector General s Office and State and federal law enforcement partners 2. Identify key metrics for your investigations Unit to ensure effective investigations, audits, recoupments and referrals to law enforcement 3. Discuss potential Impact of CMS Medicaid Managed Care rulemaking for Program Integrity in Managed Care 2 1
Collaboration Key to Successful Oversight Federal Government Federal Agencies State Law Enforcement State Agencies & MCOs Federal Law Enforcement 3 Fraud and Abuse Control Program Integrity Partners MFCU Federal HHS OIG Department of Justice FBI CMS Guidance Regulations State & Federal Law Enforcement Partners Managed Text Care Organizations Compliance and Special Investigation Units State Medicaid Department Program Integrity Units OIG 4 2
Constitution Legislative Executive Judicial Congress Office of the President Departments Federal Court System Department of Justice Department of Health and Human Services 13 other Departments Criminal Division Civil Division 94 US Attorneys Offices Office of Inspector General Centers for Medicare and Medicaid Services 24 other Departments 5 Federal Enforcement State Centers of Medicare and Medicaid Services United State s Attorney General s Department of Justice (DOJ) HHS Office of the Inspector General (HHS OIG) HHS OIG Investigators The Federal Bureau of Investigators (FBI) Internal Revenue Service State Attorney General State Medicaid Agency Inspector General Medicaid Fraud Control Units Local Law Enforcement Other: Federal / State Task Forces Private Insurance Investigators Managed Care Compliance Teams MCO Special Investigation Units 6 3
Accountability for Medicaid Expenditures State level Medicaid Criminal Fraud Prosecution Unit The MFCU conducts a Statewide program for investigating and prosecuting fraud in the administration of the Medicaid program, the provision of medical assistance, or activities of Medicaid providers. 42 U.S.C. 1396b(q); 42 C.F.R. 1007.11 Federal & State Criminal & Civil Law Enforcement State & federal Law Enforcement Agencies US Attorneys / Attorneys General Offices represent governmental interests at the State and federal level Local Law enforcement local District Attorneys or State s Attorneys State OIG /PI MFCU MCO State Medicaid Agency State level OIG / Program Integrity Units Provider Screening & Monitoring Administrative Sanctions Liaison for Law Enforcement Coordination of investigations & referrals, payment suspensions Statewide audits & investigations Data Mining for FWA Statewide Preliminary analysis to determine the sufficiency of the complaint Peer reviews, referral for selfdisclosure, etc. State level Medicaid MCO Compliance Teams Compliance Plan Policies and Procedures that guard 42 U.S.C. against 455 fraud and abuse Compliance Officer and Compliance Committee accountable to senior management Effective Training and Education for compliance officer and employees Effective lines of communication Well publicized disciplinary guidelines Internal program integrity monitoring and auditing Prompt response to detected program integrity concerns/caps 42 CFR 438.608 7 Effective Collaboration in Managed Care Oversight Ensure Collaboration between Law Enforcement Partners Ensure Quality FWA Reporting and Referrals Ensure Quality Investigations and Audits 8 4
Effective Collaboration Regular communication Regular Meetings between MCOs and Law Enforcement Monthly Ad hoc SemiAnnual Meetings Task Force Meetings 9 Monthly & Quarterly Meetings Review of MCO Program Integrity Activities & FWA work plan Review MCO investigations, data analysis, & adverse actions by MCO Opportunity for ongoing guidance Identification of high risk areas Ensure quality investigations & referrals 10 5
Ensure Quality & Uniform Reporting Ensure Consistent Reporting Requirements New Program Integrity Activities Adverse Actions Tips Preliminary Investigations Full Investigations/ Referrals Audits Initiated & Completed Overpayments Identified/ Recovered Outliers Lock In Program 11 Quality Referrals from MCO Identifying Information for Provider, including name, NPI and any other known ID # Contract(s) with MCO Credentialing Information Disclosure(s) Provider Education; including that specific to activity under review Fee Schedule Audits/Communication Medical records and all supporting documentation Information on Pre pay; including Reason(s), Status and History MCO Policy violation Relevant regulations and laws Provider participation history & status Records reviewed MCO Coders Report Other pertinent Information 12 6
Effective Program Integrity Data Analytics Data Mining Data Detection Systematic review Member Fraud: Prevention & Criminal Investigations Benefit Reviews and Analysis Qualified Staff Auditors Investigators Data Analysist Medical Coders & Healthcare Professionals Prevention: Provider Screening and Monitoring Pre-Payment Edits Pre-payment Audits Provider Fraud Investigations & recoupments Medical Reviews Medical coding 13 Effective Use of Data Double Billing Claims Processing Edits Overpayments Policy Outliers CPT Codes 7
Audits Purpose Criteria Scope Method 15 Fraud Analysis Unclear regulations or communication Poor communications with provider Documentation issues Services rendered lacking detail or format Regulatory requirement not essential to payment or quality of health service Authorization from Agency Broad impact Clear program violation False documentation Altered medical records Pattern of bad conduct Services not rendered Substitution of cheaper alternatives Differential billing for Medicaid Crime/ Loss Forgery Theft Drug Diversion Embezzlement Anti kickback Identity Theft False Claims 16 8
PROPOSED PROGRAM INTEGRITY RULES FOR MEDICAID MANAGED CARE 17 Proposed Medicaid Rules Rules Impacted: 42 CFR 431, 433, 438, 440, 457, 495 Proposed rule published June 1, 2015 Public comments due July 27, 2015 Document Citation: 80 FR 31097 Link: https://federalregister.gov/a/2015 12965 Comments can be found: http://www.regulations.gov/#!docketbrowser;rpp=25;po=0; D=CMS 2015 0068 18 9
Subjects covered by Proposed Rules: Actuarial Soundness of rates to Medicaid managed care plans Risk Sharing agreements Medical Loss Ratio Quality Improvement Strategy Network adequacy standards Accreditation Plan Payments to Providers Program Integrity 19 Provider Screening and Enrollment All providers contracted with Managed Care companies must be enrolled in Medicaid and periodically evaluated by the State State assumes responsibility for screening activities Managed care plans may still conduct their own additional level of provider screening or incorporate other screening requirements into their contracts Proposed 42 CFR 438.602(b) and 438.608(b) 20 10
Disclosures of Affiliations and Ownership/Interest Managed care plans and its subcontractors must disclose affiliation with debarred, suspended, or otherwise excluded individuals States must review ownership and control interest statements submitted by managed care plan and its subcontractors States must check monthly for exclusion sanctions Proposed 42 CFR 438.602(c) and 438.608(c)(1) and (2) 21 Data Submission and Verification Managed care plans to submit data to State: Encounters The basis for state certification of actuarial soundness in capitation rates Compliance with the MLR Adequate provision against risk of insolvency Compliance with availability and access of services and provider network adequacy Ownership and control Annual report of overpayment recoveries CEO or CFO must certify the accuracy and completeness and truthfulness Most rules of the information based on a reasonably diligent review Proposed 42 CFR 438.604 and 438.602 22 11
Provider Payment Suspension Managed care plans are to suspend payments to providers for which the state determines there is a credible allegation of fraud or pending investigation (42 CFR 455.23) Proposed 42 CFR 438.608(a)(8) 23 Recovery Overpayments If MCO recovers $ from Provider because the Provider was subsequently excluded from Medicaid or as a result of its FWA activities, the MCO may keep what it recovered. However: States are expected to take such recoveries into account in the development of future capitation rates. Requires Plans to require Providers to report overpayments and refund to Plans within 60 days of overpayments. Proposed 42 CFR 438.608(d)(1) and.608(d)2) 24 12
Seven elements of effective Compliance Plans Expands current requirements to make more robust: P&Ps Role of Compliance Office Requirements of the Regulatory Compliance Committee Internal Monitoring and Auditing Program SIU: coordination with State Program Integrity Unit Information exchange with State Proposed 42 CFR 438.608(a)(8) 25 Mandatory Reporting by Managed Care Plans All improper payments identified or recovered, specifying the improper payments due to potential fraud, to the State or law enforcement. Information about changes in an enrollee's circumstances that may affect the enrollee's eligibility including all of the following: Changes in the enrollee's residence or notification of an enrollee's mail that is returned as undeliverable. Changes in the enrollee's income. The death of an enrollee. Provider changes including termination of provider agreement. Direct referrals of fraud to Medicaid Fraud Control Unit Proposed 42 CFR 438.608(a)(2) 26 13
Medical Loss Ratio Standard Plans may include costs associated with program integrity activities (described in 438.608(a)(1) through (5), (7), (8) and (b)) in the numerator of the Medical Loss Ratio, limited to 0.5% of premium revenue. Proposed 42 CFR 438.608(a)(2) 27 Questions? 28 14