NC Department of Health and Human Services DMA Program Integrity: Medicaid Managed Care (1915 b/c...

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

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DMA

Program Integrity:Medicaid Managed Care

(1915 b/c Waivers)

Patrick O. Piggott, MSW, LCSW, DCSWChief, Behavioral Health Review Section

Program IntegrityOctober 26, 2012

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DMA

Program Integrity

References/Authority:42 CFR 438 (Managed Care)

42 CFR 434 (Contracts)

42 CFR 455 and 456 (Program Integrity & Utilization Control)

NC Medicaid State Plan

NCGS 108A – 70.10 thru 70.17 (False Claims)

NCGS 108C (Medicaid and Health Choice Provider Requirements)

10A NCAC 22F (Program Integrity) soon to transfer to 10A NCAC 24F

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DMA

“Using the Power of the Medicaid Program to improve the standard of care for Medicaid recipients across the State of North Carolina”

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DMA

Mission Statement

It is the mission of Program Integrity to ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupment, and identifying avenues for cost avoidance.

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DMA

Medicaid Landscape

• Medicaid Behavioral Health services are provided to recipients in all 100 North Carolina counties.

• The Current number of eligible Medicaid recipients is 1.5 million and HealthChoice is approximately 130,000 recipients with possible expansion by 2014.

• Over 14,000 Behavioral Health Providers (MH/SA/IDD)

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DMA

Objectives

Participants will be able to:

1. Define fraud and abuse

2. Use PI toolkit as a template for MCO PI activities

3. Identify liaisons assigned to MCO

4. List the role & responsibilities of DMA PI Liaisons

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Objectives

5. List members of an Special Investigations Unit

6. Identify the roles and responsibilities of an SIU

7. Obtain knowledge regarding Managed Care Requirements IAW 42CFR 438

8. Understand DMA’s response to MCO referral

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Objectives

9. List items to report to DMA–PI on Attachment AA

10. Respond to MCO Investigation

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Program Integrity

Toolkit for Success:

•Liaisons and contact information•Federal regulations, State Statues, and Rules•Program Integrity Policies, Procedures, and Processes•Forms•Audit and Review Tools•MIU Referral & Supplemental•Allegation Packets•Copy of Presentation

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DMA

Program Integrity

Provider Abuse

Means provider practices that are inconsistent with sound fiscal, business, or medical practices, and results in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid program

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Program Integrity

Provider Fraud

Intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitute fraud under applicable Federal or State law.

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Program Integrity

Waste

The misuse, underutilization, or overutilization of items or services or other inappropriate or unnecessary billing or medical practices that directly or indirectly add to healthcare costs or unwarranted or unexplained variation in care that results in no discernible differences in health or patient outcomes

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Program Integrity

Quality of Care Concerns

•Clinical and practice issues that are identified by the utilization review during a review of clinical information submitted by providers for the purpose of requesting authorization to provide Medicaid funded behavioral health services; or

•Reported by a complainant about the care or services a recipient or consumer has or has not received

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Program Integrity

False Claims Act 31 U.S.C. §§3729-3733

Imposes liability for person or entity who:• Knowingly files a false or fraudulent claim for payments to

Medicare, Medicaid, or other federally funded health care program.

• Knowingly uses false record or statement to obtain payment on a false or fraudulent claim from Medicare, Medicaid or other federally health care program; or

• Conspires to defraud Medicare, Medicaid or other federally funded health care

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DMA

Program Integrity

False Claims Act

Medical Assistance Provider False Claims Act (MAPFC) of 1997 makes it unlawful for any Medicaid provider to knowingly make or cause to be made a false claim for payment. Under MAPFC “ “knowingly” means that a provider: • Has actual knowledge of the information• Acts in deliberate ignorance of the truth or falsity of the

information; or • Acts in reckless disregard of the truth or falsity of the

information. No proof of specific intent to defraud is required.

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Program Integrity

Investigation

Program Integrity activity designed to collect facts and make a determination regarding a concern, complaint, or referral on a provider, contractor or beneficiary potentially engaged in FWA

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Program Integrity

Audit

Program Integrity activity designed to determine if providers are compliant with rules, regulations, policies, and guidelines

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Program Integrity Liaisons

•James Springer: ECBH and CostalCare

•Mary Bracey: Sandhills

•Kathy Reid: Eastpointe

•Elaine Robinson: CenterPoint

•Ella Peebles: Alliance Behavioral Healthcare

•Pamela Toney: Back-up

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Program Integrity Liaisons

•Monique Loh: MeckLink and Partners

•Jean Sibbers: Smokey Mountain Center and Western Highlands Network

•Patrick Piggott: PBH

•Rodney Ferguson: Back-up

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DMA

Roles & Responsibilities

• Lead investigations of complaints or leads regarding fraud, waste, or abuse by MCO

• Conduct a review of all MCO cases referred to DMA regarding potential fraud

• Resolve complaints in an efficient and timely manner

• Serve on Interdepartmental Monitoring Teams (Implementation and Monitoring)

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Roles & Responsibilities

• Review and approve Compliance Plans

• Make recommendations regarding MCO PI activities

• Follow-up on monthly PI reporting activities

• Participate in monthly MCO PI meetings

• Participate in Quarterly Statewide PI-MCO meeting to review cases and PI activities

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Roles & Responsibilities

• Update MCO on provider good standing status, potential state-wide issues, payment suspension, investigations, etc

• Educate MCO regarding Program Integrity activities and update on new federal or state laws, rules, regulations.

•

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DMA

MCO Special Investigations Unit

• Supervisor

• Clinical Analyst

• Investigator

• Data Analyst

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MCO Special Investigations Unit

• Handle all program integrity activities in the MCO

• Responsible for postpayment reviews in accordance with 42 CFR 456 and prepayment review activities

• Conduct random reviews of provider contracts and subcontracts

• Meet with DMA PI and AGO-MID quarterly

• If there is an allegation of fraud, investigate the allegation by conducting at a minimum, a desk review

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MCO Investigation

• Receive complaint or lead

• Determine if complaint is valid (recipient and provider eligibility)

• Assign case to an Investigator

• Review parameters

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MCO Investigation

• Develop strategy – Planning meetings & logistics– desk review vs. onsite– announced vs. unannounced– small vs. large sample– Time period– Recipient, staff, complainant, or corporate interviews

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MCO Investigation

• Pull population & sample

• Entrance conference

• Conduct audit/investigation

• Exit Conference

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MCO Investigation

• Consolidate and summarize findings

• If extrapolation, use the DMA standard protocol

• Determine if the case involves potential fraud–Know the definition–Connect the dots

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MCO Investigation

•If potential fraud, complete Referral form to DMA with all supporting documentation and information (using best practice standard)

•If abuse, render MCO administrative sanctions and remember to report on attachment AA. (only recoup once on a specific claim)

•Attachment AA, Program Integrity activities is due by 5th of the Month to Program Integrity (Liaison/Chief)

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

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DMA

DMA Response to MCO Referral

•Receive cases of potential Fraud from MCO. DMA will conduct a preliminary Review

•Determine if case warrants a referral to Medicaid Investigation Division.

•If not an appropriate referral, may request additional documentation or information, or recommend MCO administrative action.

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DMA Response to MCO Referral

• The State’s AG’s office, MID and the US Attorney’s Office has the authority to investigate and prosecute Medicaid fraud

• The lack of knowledge is not a defense for fraud.

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MCO Referral: Provider

Content:

•Provider name and NPI number

•The provider’s address

•The provider type

•The source of the allegation

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MCO Referral: Provider

Content:

•The nature of the allegation

•Description of intentional misconduct

•The dollar amount paid to the provider over the last three years

•Copies of all communication between MCO and the provider

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DMA

MCO Referral: Provider

Content:

•Contact information for LME-MCO staff with practicalknowledge of the workings of the relevant programs

•Date reported to the State, and

•Legal and administrative status of the case

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MCO Referral: Beneficiary

Content:• The beneficiary’s name and MID#

• The Source of the allegation

• The nature of the allegation

• Copies of all communication between MCO and recipient/complainant concerning the issue

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MCO Referral: Beneficiary

Content:

• Contact information for LME-MCO Staff having knowledge of the allegation

• Date reported to the State, and

• Legal and administrative status of the case

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

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MCO Referral:

Send to:Division of Medical Assistance

Program Integrity-BIC2501 Mail Service CenterRaleigh, NC 27529-2501

Format:2 copies and on encrypted/secured CDs/flashdrive

Email to:_____@dhhs.nc.gov (under development)

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Post-Payment Reviews

• Determine if provider delivered services that were medically necessary

• Determine if provider delivered services in compliance with Clinical Coverage policies, guidelines, rules, and regulations

• Or any other target concern to prevent financial loss to the Medicaid managed care program

*Consistent across MCO

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Sanction Options

• Termination of provider’s participation• Withholding Payments• Recoup overpayments• Warning Letters for when overpayment is $150 or less• Educational letters for provider• Suspension of a provider for a period of time• Prepayment Claims Review

*Consistent across MCO

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Reporting: Attachment AA

• Terminations • Withholding Payments • Recoup overpayments• Warning Letters for when overpayment is $150 or less• Educational letters for provider• Suspension of a provider for a period of time

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Reporting: Attachment AA

• Prepayment Claims Review• Self Audits(include reasons, effective dates, and $amounts if

applicable)

• Denial of credentials

• Denial of enrollment

• Denial of contracts

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Managed Care Requirements

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MCO Responsibilities

MCO are required to ensure integrity in the Medicaid Managed Care Program and ensure “Services are provided in…the best interest of the

Recipients.”

Establish clear policies and procedures for the selection and retention of providers

Monitor providers regularly to determine compliance

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

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MCO Responsibilities

Take corrective action if there is failure to comply

Develop mechanism to detect both utilization and overutilization of services

Develop mechanism to assess the quality and appropriateness of care

Ensure providers are credentialed and re-credentialed

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MCO Responsibilities

At a minimum must have administrative and management arrangements or procedures including:

•Mandatory compliance plan designed to safeguard against fraud and abuse in the Medicaid Managed Care program

•Written policies and procedures and standards of conduct that articulate the organizations commitment to comply with all federal and state standards

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MCO Responsibilities

Minimum cont.

• Designate a compliance officer

• Training & education for the compliance officer and organization employees

• Lines of communication between compliance officer and the organization employees

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MCO Responsibilities

Minimum cont.

• Enforcement of standards through well publicized disciplinary guidelines

• Provisions for internal monitoring and auditing

• Specifies certain prohibitions aimed at the prevention of fraud and abuse.

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MCO Responsibilities

•Must establish safeguards against conflicts of interests on the part of State & local officers and employees and agents of the State who have responsibilities related to the MCO Contract

•Prohibit affiliations with individuals debarred by Federal agencies and other Federal health care programs

– Individuals who are debarred, suspended, or otherwise excluded from participating in procurement activities and non-procurement activities (director, officers, partner, 5% ownership, employee, consultant, or other arrangement)

•Provisions for prompt responses to detected offenses and the development of corrective action initiatives

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Compliance

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

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Adherence to all applicable statutory, regulatory, & Medicaid Managed Care program requirements (see slide 2)

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• Conduct your self assessment, evaluations and mock reviews to ensure compliance with all rules, regulations, and policies

• Commitment to ethical and legal business conduct.

• Responsibility to provide ethical leadership and to ensure that adequate systems are in place to facilitate ethical and legal conduct

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•Establish internal controls and monitor agency conduct to reduce the risk of unlawful or improper activities

•Requires a substantial commitment of time, energy and resources

•A cost-effective investment.

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What happens when things do not go as

planned?

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On-site Investigation

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Respond to an Investigation

• Cooperate• Comply by producing the documents and information requested• Prepare an area for Investigators to conduct the investigation/Audit• Entrance Conference, fact finding, and exit conference• Administrative Action• Findings of an investigation may be referred to the MID, Attorney

General’s Office.• The State’s MID, AG’s office and the US Attorney’s Office has the

authority to investigate and prosecute Medicaid fraud

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Summary

• Know Federal and State, rules, regulations, rules, guidelines, and policies

• Use the PI toolkit to support MCO PI Activities

• Reporting PI Activities on Attachment AA

• Managed Care Requirements and Contract

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Summary

• Program Integrity Liaisons and contacts

• Compliance & Risk

• Investigation of MCO

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QUESTIONS or COMMENTS

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CONTACT:Patrick O. Piggott, MSW, LCSW, DCSW

Chief, Behavioral Health Review SectionNC DMA – Program Integrity

Phone: (919) 647-8049Fax: (919) 647-8054

Email: Patrick.Piggott@dhhs.nc.gov