12.2M 78.3M Medical Offices: 690 · • Extensive and diverse experience in the investigation of criminal wrongdoing in public (law enforcement) and private sectors:--Health Care

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Building an SIU that is nimble and audit ready

HCCA Managed Care Compliance ConferenceJanuary 27 – 30, 2019 | Lake Buena Vista, FL

Marita Janiga, Executive Director, Ethics & Compliance Investigations

Tamara Neiman, Director, Ethics & Compliance Investigations, National Special Investigations Unit

Mark Horowitz, Sr. Manager, Enterprise Regional Ethics & Compliance, Care Delivery & Pharmacy

1 | Copyright © 2019 Kaiser Foundation Health Plan, Inc.

HCCA Managed Care Compliance Conference

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Kaiser Permanente Facts

8including D.C.

Regions

Nurses: 58,345Physicians: 22,013

Nurses and Physicians

217,173

Employees

Hospitals: 39Medical Offices: 690

Hospitals & Medical Offices

78.3M

Annual Prescriptions Filled

12.2M

Members

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Ethics & Compliance Investigations

Compliance Investigations

Case Management &

Reporting Unit

National Special

Investigations Unit

National

Fraud Control

Unit

Strategy &

Program Manage

ment

HOTLINE

HCCA Managed Care Compliance Conference ?

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2017 Report Volumes

Hotline (3rd party vendor)

Reported directly to Compliance

5284 cases 7070 cases

2.5 Hotline calls per employee

(Navex Global Inc. industry benchmark: 1.4 per 100 employees)

2.6 DE cases per employee

Anonymous: 60% Anonymous: 4%

Non-Anonymous: 40% Non-Anonymous: 96%


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Integrate Systemness

Triage every case using our

national assignment directory

Single case management system

Report and monitor trends


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Executive Director, Ethics & Compliance

Investigations

Director, National Special

Investigations Unit (NSIU)

Sr. Manager, Enterprise Regional Compliance: Care

Delivery & Pharmacy

Analyst(4)

Manager(3)

Senior Investigator

(11)

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• Extensive and diverse experience in the investigation of criminal wrongdoing in public (law enforcement) and private sectors:

--Health Care Fraud --Criminal Investigations--Medicare Fraud --Drug Trafficking--Medicaid Fraud --Claims Review--Financial Crimes --Sex Crimes--Internal Revenue Service Audits --Terrorism Task Force

• Receive ongoing specialized training from recognized professional anti-fraud organizations.

• Participate in health care fraud task forces, including the joint law enforcement / private sector task forces sponsored by the U.S. Attorney's Offices.

Experienced Investigators


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When to Consult with NSIU

Our company

• Potential harm to KP• Potential harm to our

members, staff or the public

• Reputation issues• Potential media

exposure

Financial Impact

• Dollar loss over $10,000

Government

• Outside agency involvement (regulators)

• Legal implications• Potential criminal

implications• Contacted by law

enforcement

Regulators Law Enforcement

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• Fraud, Waste and Abuse (FWA) Allegations (over $10,000)• Pharmacy Theft / Drug Diversion • Member Fraud• Identity Theft• Health Care / Claims Fraud• Privacy / Computer Fraud

• Cash / Check Fraud• Embezzlement • Vendor Fraud • Kickbacks• Major Crimes

637 cases opened in 2017

National Special

Investigations Unit

Which of the categories below, represents 49 % of our cases?


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Partnership

• Internal Audit • Legal• Pharmacy• Regions• HR

Agile

• Training• Referrals• Annual work plan• Risk assessment• Request for Information (RFIs)

Our success

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Source https://oig.hhs.gov/newsroom/media-materials/2018/takedown/


# of RFIs process

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How many RFIs do you think our team processed in 2018?

A.1050

B.1189

C.1425

D.1579

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Preparing for a CMS Audit

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Integrate Systemness

Ethics and Compliance Investigations and Operations coordinate Kaiser Permanente’s responses that are managed by the Ethics and Compliance Medicare Health Plan team.

• Medicare Monitoring Program (Medicare requirements metrics that measure operational performance outcomes).

• Audits: Compliance Program Effectiveness, Medicare Advantage Organizations (MAOs) and Medicare Prescription Drug Plan (PDP) functional areas.

• Centers for Medicare & Medicaid Services (CMS) regulatory and sub-regulatory guidance communication and tracking (i.e., new CMS issuances).

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How to respond to CMS memos and issuances

How clinicians partner with NSIU to submit referrals to National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)

How to prepare the tracer during a CMS audit

Topic 6

Learning Objectives

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Compliance and Fraud, Waste, and Abuse Data Mining

Proactive

Reactive

CMS Memos

Three-pronged approach

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Receive CMS memos

and alertsDocument

the processClose the

loop through referrals

Partner with Pharmacy

Benefit Manager (PBM)

Merge disparate data

1 4 52 3


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1

Receive CMS memos

and alerts

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2

Document the process


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3

Data Visualization

List of pharmacies

List of providers

Prescription drug event

claims

596 pharmacies x 56 data elements = 33,376 total data elements.

Merge disparate

data

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March 2016 Data Visualization

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Merge disparate

data


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Find the Nugget

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Merge disparate

data

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After reviewing the data, we found a non-Kaiser Permanente provider writing for our Medicare members with an average of 770mg morphine equivalent dose / day prescription dispensed from a non-Kaiser Permanente pharmacy.

Non-Kaiser Permanente provider.

Non-Kaiser Permanente pharmacy.

Concerning medical chart note.

Monthly prescriptions:

1. Methadone 10mg #140

2. Morphine ER 200mg #84

3. Oxycodone 30mg #56

3Merge

disparate data


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3

Merge disparate

data

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4 Partner with Pharmacy Benefit Manager (PBM)

After reviewing the data and investigative information, we identified the following findings.

Top five medications:

1. Oxycodone 30mg

2. Oxycontin 80mg

3. Oxycodone/APAP 10-325

4. Clonazepam

5. Gabapentin

Link from nurse practitioner to MD.

Diagnosis code: M54.5 & M96.1 for lower

back pain, post-laminectomy syndrome.


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4 Partner with Pharmacy Benefit Manager (PBM)

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4Partner with Pharmacy Benefit Manager (PBM)

Pharmacist

Medicine & Surgery


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4Partner with Pharmacy Benefit Manager (PBM)

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Close the loop through referrals

NBI MEDIC referral

PLATO®

entry

PBM referral and

termination

HFPP*

entry

* Healthcare Fraud Prevention Partnership


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5The NBI MEDIC is currently investigating pharmacy, NPI 1942494166.• This investigation was opened as the result of a

Kaiser Permanente referral.• The NBI MEDIC is requesting any records or

notes obtained as part of the investigation.

SIRIS entry

NBI MEDIC investigation

RFI received

Criminal Investigation

NBI MEDIC informed KP about the providers. • Seven patients 60 years old or younger died of an

opioid overdose under physician care.• Two patients 60 years old or younger died of an

opioid overdose under nurse care.

On June 2017, the ‘pharmacy’ was terminated from Kaiser Permanente’s pharmacy benefit management (PBM).

Close the loop through referrals

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What should plan sponsors do?

Fill it out.

Complete three separate timelines.

Provide supporting documentation:

1. Training2. Communication

Engage subject matter experts.

How to Prepare the Tracer during a CMS Audit


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Fill it out (10 Pages):

1. Background and issue2. Prevention3. Detection and reporting4. Correction


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Fill it out.



Timeline One – Overview Timeline Two – Beneficiary Level Timeline Three – PBM


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Fill it out.


Provide supporting documentation:

1. Training2. Communication

How to Prepare the Tracer during a CMS Audit • Delivered 27 drug-seeking

behavior trainings with 1,775+ attendees during the audit period

• CMS fraud, waste, and abuse webinar September 13, 2016

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Preparing for a CMS Audit

Key Takeaways

Process for responding to

CMS memos and issuances

Importance of clinician and

SIU partnership related to

NBI MEDIC referral

Steps taken to prepare for

CMS tracer audit

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Building a nimble and audit ready special investigations unit (SIU)

Key Takeaways

Integrate systemness Form strong partnership Selecting the right people

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Questions?


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[email protected] (510) 271-6937



Documents

12.2M 78.3M Medical Offices: 690 · • Extensive and diverse experience in the investigation of criminal wrongdoing in public (law enforcement) and private sectors:--Health Care