503 ProgramIntegrity · 2015-01-27 · Project (Medi-Medi) 3. State False Claims Acts (FCA) ... Acronym Tracker (AcTrac) How many have we used so far? UHC C&S FY DRA MIP Medi-Medi

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Breaking Down Program Integrity –

What’s Required and (More Importantly) What’s Needed

Chris Zitzer, JD, CHC

Chief Compliance Officer

Emily Aurand, CHC

Associate Director of Compliance

HCCA Managed Care Compliance Conference

Las Vegas, NV

February 17, 2015

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Confidential Property of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

Who is UHC Community & State?Serving over 4.8 million members

HI

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Indicates C&S footprint

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Program IntegrityThe Basics

Program IntegrityWhat is it?

Medicaid Integrity: Planning, prevention, detection, and investigative/recovery activities undertaken to minimize or prevent overpayments due to Medicaid fraud, waste, or abuse. (Source: CMS Medicaid Program Integrity Manual)

Medicare Advantage Organizations / Part D Plan Sponsors -

Mandatory Compliance Program: Adopt and implement an effective compliance program, which must include measures that prevent, detect, and correct non-compliance with CMS’ program requirements as well as measures that prevent, detect, and correct fraud, waste, and abuse.(Source: 42 CFR§ 422.503(b)(4)(vi))

Proprietary Information of UnitedHealth Group. Do not distribute or reproduce without express permission of UnitedHealth Group.

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Fraud, Waste & Abuse in the SystemHow Big is the Issue?

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Medicare:

In FY 2014, Medicare covered more than 50 million individuals at a cost of about $595 billion.

Estimated $36 billion in improper fee-for-service payments in FY 2013

SOURCE: Medicare Program Integrity: Increased Oversight and Guidance Could Improve Effectiveness and Efficiency of Postpayment Claims Reviews, GAO Report to Congressional Requestors (July 2014)

Medicaid:

In FY 2013, Medicaid covered about 71.7 million individuals at a cost of about $431 billion.

Estimated $14.4 billion in improper payments in FY 2013 (5.8 percent of Medicaid spending)

SOURCE: Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures, GAO Report to the Senate Finance Committee (May 2014)

BackgroundGrowth of Program Integrity

Deficit Reduction Act of 2005 (DRA)

• Four Key priority areas:

1. Prevention

2. Detection

3. Transparency and accountability

4. Recovery

Three important provisions:

1. Medicaid Integrity Program (MIP)

2. Medicare-Medicaid Data Matching Project (Medi-Medi)

3. State False Claims Acts (FCA)


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BackgroundGrowth of Program Integrity

Affordable Care Act of 2010 (ACA)

• Additional investment in Program Integrity:

1. $350 million over 10 years

2. Provider screening and data-matching

3. Authorities to federal and state agencies and contractors to take action

4. Program coordination and state-to-state collaboration opportunities

5. Collaboration efforts across payers and states


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Program IntegrityBeyond “Pay and Chase”

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Program IntegrityKey Terms

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For detailed definitions of terms, see source: Medicare Fraud & Abuse, Prevention, Detection and Reporting, Medicare Learning Network (August 2014)

Acronym Tracker (AcTrac)How many have we used so far?

UHC

C&S

FY

DRA

MIP

Medi-Medi

FCA

ACA/PPACA

CMS

MACPAC

FWA

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Program IntegrityWhat Entities are Involved?

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Program IntegrityKey Players - Medicaid

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Federal:

• Centers for Medicare & Medicaid Services (CMS)

• Department of Justice (DOJ)

• Office of Inspector General (OIG) of the Department of Health and Human Services (HHS)

• Government Accountability Office (GAO)

State:

• State Medicaid Agency

• Medicaid Fraud Control Unit (MFCU)

• OthersSOURCE: Program Integrity in Medicaid: A Primer, Kaiser Commission on Medicaid and the Uninsured (July 2012)

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Program IntegrityKey Players – Medicaid (Another View)

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SOURCE: Medicaid Program Integrity: Increased Oversight Needed to Ensure Integrity of Growing Managed Care Expenditures, GAO Report to the Senate Finance Committee (May 2014)

Acronym Tracker (AcTrac)This is starting to get ridiculous. . .

MCO

DOJ

GAO

OIG

HHS

CPI

MedPAC

MFCU

RAC

SURS

PIU

OFM

ZPIC

MIC

SIU

MIG

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Program IntegrityWhat Key Initiatives Are Underway?

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Key InitiativesEfforts to Coordinate Across Medicare & Medicaid

National Fraud Prevention Program (NFP)

Termination of Provider Participation

Medicare-Medicaid Data Matching Project (Medi-Medi)

Fraud Prevention System for Medicare

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Key InitiativesEfforts to Collaborate with States

The Medicaid Integrity Institute (MII)

Medicaid Integrity Group (MIG) Efforts to Target High-Fraud Areas

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Key InitiativesAudit and Oversight Efforts (Medicaid)

Medicaid Integrity Contractors (MICs)

Recovery Audit Contractors (RACs)

Payment Error Rate Measurement Program (PERM)

Medicaid Eligibility Quality Control Program (MEQC)

Medicaid Integrity Group (MIG)

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Key InitiativesAudit and Oversight Efforts (Medicare)

Comprehensive Error Rate Testing (CERT)

Medicare Administrative Contractors (MACs)

Medicare Drug Integrity Contractors (MEDICs)

Recovery Audit Program Recovery Auditors

Zone Program Integrity Contractors (ZPICs)

Center for Program Integrity (CPI)

CMS Program Effectiveness Audit – Compliance Program Audit Protocols

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Key InitiativesLaw Enforcement Efforts

Federal False Claims Act (FCA)

Health Care Fraud and Abuse Control Program (HCFAC)

Health Care Fraud Prevention and Enforcement Action Team (HEAT)

HHS OIG Medicare Fraud Strike Force (slide 21)

U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) Work Plan (slides 22-24)

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Law Enforcement EffortsMedicare Fraud Strike Force

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Source: Medicare Fraud Strike Force, HHS Office of Inspector General,https://oig.hhs.gov/fraud/strike-force/, accessed December 17, 2014

2015 OIG Work PlanMedicaid Managed Care

State Payments to Managed Care Entities

• Medicaid managed care reimbursement

• Medical loss ratio – Managed care plans’ refunds to States

• MCO payments for services after beneficiaries’ death (new)

• MCO payments for ineligible beneficiaries (new)

Data Collection and Reporting

• Completeness and accuracy of managed care encounter data

Program Integrity in Managed Care

• Medicaid managed care entities’ identification of fraud and abuse

Beneficiary Protections in Managed Care

• Beneficiary access to services under Medicaid managed care

• Medicaid managed care beneficiary grievances and appeals processes

• Oversight of managed care entities’ marketing practices

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2015 OIG Work PlanMedicare Part C and Part D

MA Organizations’ Compliance With Part C Requirements

• Encounter data—CMS oversight of data integrity

• Risk adjustment data—Sufficiency of documentation supporting diagnoses

Part D – Prescription Drug Program

• Medicare, Sponsor, and Manufacturer Policies and Practices

� Savings potential of adjusting risk corridors

• Sponsor Compliance With Part D Requirements

� Documentation of administrative costs in sponsors’ bid proposals

� Reconciliation of payments—Sponsor reporting of direct and indirect remuneration

� Reconciliation of payments—Reopening final payment determinations

� Ensuring dual eligibles’ access to drugs under Part D

� Recommendation follow-up: Oversight of conflicts of interest in Medicare prescription drug decisions (new)

• Part D Billing and Payments

� Documentation of pharmacies’ prescription drug event data

� Medicare payments for HIV drugs for deceased beneficiaries

� Quality of sponsor data used in calculating coverage-gap discounts

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2015 OIG Work PlanCMS-Related Legal and Investigative Activities

Legal Activities

• Exclusions from Program Participation

• Civil Monetary Penalties

• False Claims Act Cases and Corporate Integrity Agreements

• Providers’ Compliance With Corporate Integrity Agreements

• Advisory Opinions and Other Industry Guidance

• Provider Self-Disclosure

Investigative Activities

• Medicare Fraud Strike Force Teams and Other Collaboration

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Key InitiativesState Efforts

Data Collection and Analysis

Provider Enrollment Processes

Provider Education & Communication

Oversight of Personal Care Services

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Source: 2014 Annual Summary Report of Comprehensive Program Integrity Reviews, CMS Medicaid Integrity Program, (June 2014)

Acronym Tracker (AcTrac)OMG! No wonder nobody understands us. . .

NFP

MII

PERM

MEQC

CERT

MAC

MEDIC

HCFAC

HEAT

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Program IntegrityCurrent State of the Industry and What is Needed?

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Medicaid Program IntegrityGAO Report to Senate Finance (May 2014)

Key Findings:

1. Managed Care presents a gap in Medicaid Program Integrity efforts;

2. Federal entities have taken few steps to address Medicaid managed care Program Integrity; and

3. Fragmentation exists and coordination efforts raise benefits and challenges.

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Medicaid Program IntegrityGAO Report to Senate Finance (May 2014)

Recommendations to CMS:

Increase its oversight of program integrity efforts by:

1. Requiring states to audit payments to and by MCOs;

2. Updating its guidance on Medicaid managed care program integrity; and

3. Provide states additional support for managed care oversight, such as audit assistance from existing contractors.

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Program IntegrityTakeaways for Managed Care Organizations

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UnitedHealthcare ComplianceHow We Help the Business Succeed

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• We seek to proactively understand our health plans’ needs in order to offer timely advice and innovative solutions to compliance challenges.

• We stay on top of changes in the regulatory environment to effectively anticipate, assess and respond to regulatory expectations.

•We regularly evaluate existing processes to identify and address opportunities for improvement.

Proactive Advisors

•We provide insightful, accurate and timely compliance reports to business leaders, government partners and Boards of Directors.

•We design and implement effective compliance programs and monitor key business processes to help reduce compliance risk and ensure strong compliance outcomes.

•We leverage our unique knowledge and skills to give prompt and sound advice in response to urgent compliance issues and situations.

Trusted Specialists

• We regularly engage and consult with the business to provide input and advice in the early stages of strategy development and decision-making.

•We stay closely aligned with our enterprise governance partners to facilitate the best compliance and risk management solutions.

•We work collaboratively with regulators as their partners to advocate on behalf of UnitedHealthcare Community & State concerning the development of new requirements.

Value-Added Partners

Value: We develop and execute innovative compliance strategies, which enable the business to deliver on the promise of UnitedHealthcare.

Mission: We are sought after as a strategic partner to help differentiate UnitedHealthcare as the company that sets the standard for integrity.

Program IntegrityComprehensive FWA Program

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7 Elements of an Effective Compliance Program

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Establishing a “Program”Written Standards

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• Code of Conduct – Standards for Ethics & Compliance• Anti-Fraud, Waste and Abuse Program Description• Supplemental Program Description for Specific Requirements • Policies & Procedures

Establishing a “Program”High-Level Oversight

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Governance and OversightProgram Integrity Oversight Committee

Ensure the maintenance of an effective program to prevent, detect, and correct suspected fraud, waste, and abuse.

Requires engagement and participation from leadership and business partners.

Key areas of focus:• Oversight structures and processes• Program transparency and

accountability• FWA investigative units • Recovery activities • Education on emerging risks and

industry standards

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Board of Directors

Compliance Oversight

Committee

Program Integrity

Oversight Committee

Establishing a “Program”Training & Education

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• Ensure all FWA training and education requirements are accounted for, including:

• Required content targets all appropriate audiences• All audiences complete training• Required timeframes for completion are met.


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Establishing a “Program”Reporting (Open Lines of Communication)

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• Ensure established and accessible Compliance, Ethics, and FWA reporting mechanisms exist for employees, providers, members, and vendors (e.g. anonymous hotline, reporting to compliance officers, etc.)

• Ensure regulatory reporting requirements are fulfilled with timely and accurate data related to investigations, recoveries, corrective actions, etc.


Establishing a “Program”Enforcement & Discipline

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• Execute clear and established non-retaliation policies, including whistleblower protections, for reporting FWA .

• Employ consistent enforcement of disciplinary actions • Develop and implement processes to take appropriate action,

including corrective action, for providers engaged in fraudulent, wasteful, or abusive billing behavior

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Establishing a “Program”Auditing & Monitoring

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• Execute against a risk-based internal audit plan that includes audits of FWA processes and supporting documentation (including vendors or subcontractors)

• Establish provider and claims auditing processes to identify abhorrent billing patterns with report out to compliance for appropriate oversight

• Monitor FWA operational outcomes to assess compliance with regulatory or contractual requirements

Establishing a “Program”Response & Prevention

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• Respond to identified risks that appear through auditing, monitoring, regulatory enforcement actions, etc.

• Establish prospective measures to prevent, detect, and investigate suspicions of FWA, non-compliance, or unethical behavior, and proactively prevent inappropriate payments as needed

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The “Eighth Element”Compliance Risk Assessment

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• A common template is used to document identified risk areas, assignment of overall risk prioritization score, assigned business owner(s), and source of compliance risk subject area.

• Risk areas are assessed a score across categories of potential impact, likelihood, and mitigation ranging from none to significant.

• An overall risk prioritization score is assigned to support a hierarchal ranking of risk areas for program and business activities (overall risk prioritization score equals the average of scores assigned to impact, likelihood, mitigation category scores).

Program IntegrityAn Integrated Approach

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Program Integrity Oversight Committee

Medicare Medicaid Commercial TRICARE

Key Compliance & Operational Leaders

Effective Program Oversight Supporting Compliant Outcomes

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Program IntegrityRole of Compliance in FWA

Ensure a framework exists for effective Compliance Program and Anti-FWA Program

Ensure established processes and proceduresexist to meet regulatory and contractual requirements

Collaborate with operational functions and ensure timely fraud reports are made to appropriate agencies

Oversee execution and completion of all required fraud training and education

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Program IntegrityRole of Legal in FWA

Advisor on key fraud and abuse laws, regulations and expectations

Partner on analyzing key issues to ensure complete view of potential risks

Establish attorney-client privilege, when appropriate

Protect the organization

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Program IntegrityRole of SIU in FWA

Perform fraud and abuse investigations

Remain apprised of the latest research available regarding new and emerging FWA schemes and practices

Identify new methodologies and technologies available to combat FWA

Monitor information regarding FWA-related arrests, indictments, prosecutions, and convictions of providers and members

Prepare and follow investigation plans and document the steps and results of the investigations

Support regulatory reporting of FWA investigation updates and outcomes

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Program IntegrityCompliance & Business Collaboration

Keys to Success

� Clarify roles and expectations, ensuring accountability remains within the business

� Be clear about what is required and what is needed to meet state and federal expectations

� Establish agreed upon measures of success (and how to get there)

� Identify the most significant Program Integrity risks through established risk assessment processes

� Define what it means to be audit ready

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Measuring Program Effectiveness Compliance Scorecard

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Structure x

Process x

Outcomes =

Effectiveness

Acronym Tracker (AcTrac)The Final Tally

UHC

C&S

FY

DRA

MIP

Medi-Medi

FCA

ACA/PPACA

CMS

MACPAC

FWA

CPI

MCO

DOJ

GAO

OIG

HHS

MedPAC

MFCU

RAC

SURS

PIU

OFM

AoA

ZPIC

MIC

SIU

MIG

SSA

NFP

MII

PERM

MEQC

CERT

MAC

MEDIC

HCFAC

HEAT

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Program IntegrityIn Conclusion. . .

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Contact InformationHappy to Connect!

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Chris Zitzer

Chief Compliance Officer

UnitedHealthcare Community & State

[email protected]

(952) 931-5372

Emily Aurand

Associate Director of Compliance

UnitedHealthcare Community & State

[email protected]

(952) 931-5344

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Questions

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Documents

503 ProgramIntegrity · 2015-01-27 · Project (Medi-Medi) 3. State False Claims Acts (FCA) ... Acronym Tracker (AcTrac) How many have we used so far? UHC C&S FY DRA MIP Medi-Medi