Giving Value Back to the Provider - Beacon Health Options · Committed to principles of recovery and resiliency Diverse client base • Commercial Division ... Free Internet based

Copyright © 2013 ValueOptions, Inc. All Rights Reserved.

Giving Value Back to the Provider

2013


Objectives

Overview of ValueOptions®

Giving Value Back

ProviderConnect® Demonstration

Overview of Operational Areas

Featured Presentation – Fraud Waste & Abuse

Questions and Answers

2

Copyright © 2013 ValueOptions, Inc. All Rights Reserved.3

Overview of ValueOptions


ValueOptions

Founded in 1983

Largest independent behavioral health company

Serving over 32 million members

Contracts with 20 health plans

More than 50 Medicaid contracts in 14 states

Committed to principles of recovery and resiliency

Diverse client base • Commercial Division

Employer Groups

Health Plans

• Federal Division

• Public Sector Division

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ValueOptions National Presence

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Regional support, EAP staff and corporate support offices

Major service centers

Public Program/ Medicaid Membership

National Innovation and Technology Center

AK

NM

MT

WY

COUT

ID

AZ

NV

WA

CA

OR

TX

OK

KS

NE

SD

ND

IL

MS

AR

LA

MO

IA

MNWI

FL

KY

WV VA

NCTN

SC

AL GA

RI

NJ

DEMD

ME

NY

PA

MI

VTNHMA

CT

OHIN

HI


Giving Value Back to Providers


How Does ValueOptions Give Value Back to the Providers?

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Welcome Packet

www.valueoptions.com

Provider BenefitsCEU Opportunities & Training Resources

Electronic Online Administrative ServicesProvider Designation Programs

Single Integrated Connect System

Provider Forums

Visit to Key Facilities


ValueSelect Program

A provider designation implemented by ValueOptions

Selected based on:• Accessibility

• Administrative efficiency

• Clinical and quality efficiency

• Number of complaints received from patients

• Engagement in at least one or more of the following: On Track Outcomes Program Electronic submission of at least 75% of non-EAP claims Patient completion of ValueOptions Patient Treatment Survey CEAP credentialing

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Relias and CEQuick

Relias (previously known as Essential Learning):

Free Internet based training and development program for ValueSelectSM providers

Wide variety of online CEU courses Providers take courses at their own pace ValueSelect eligibility reviewed semi-annually; if provider is

eligible, will receive an Relias welcome letter and learner manual

CEQuick Offers all of the benefits of the Relias training platform but is

available to non-ValueSelect providers at a cost.

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On Track Outcomes

A client-centered outcomes management program

Supports clinicians as they help clients achieve their goals

Utilizes a standardized, client-completed questionnaire

Provider receives rapid feedback

Disclaimer: The ValueOptions On Track Outcomes program does not make recommendations or decisions aboutappropriate clinical care or service. Any questionnaires, reports, guidelines and other material related to thisprogram are intended as an informational aid to network clinicians. They do not substitute for or limit in any waythe use of other resources and the clinician's own professional judgment in the delivery of counseling services.

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PaySpan® Health

A tool enabling you to:

• Receive payments automatically

• Receive email notifications immediately upon payment

• View your remittance advice online

• Download an 835 file to use for auto-posting purposes

Visit the PaySpan Health website at www.payspanhealth.com

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Electronic Provider Summary Vouchers (PSVs) and Authorization Letters

Electronic Clinical Notifications for Outpatient Outlier Requests forInformation

Online Provider Recredentialing

ValueOptions self-service option, ProviderConnect

Green Program Webinars: http://www.valueoptions.com/providers/Training/Training_Workshops_Archives.htm

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Up to the Minute Communications

Provider PulseSM Messages

Fax and Email Communications

Provider Mailings

Constant Contact Alerts

Monthly Valued Provider eNewsletter

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ValueOptions.com








Demonstration of ProviderConnect


ProviderConnect – Provider Online Services

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A HIPAA-secure online tool where providers can: Verify member eligibility Access ProviderConnect Message Center

Access and Print Forms Submit EAP Case Activity Forms (CAF)

Request Payment for EAP Services Request and View Authorizations

Download and Print Authorization Letters Submit Claims and View Status

Access PSVs Submit Customer Service Inquiries

Submit Updates to Provider DemographicInformation

Submit Recredentialing Applications

INCREASED CONVENIENCE, DECREASED ADMINISTRATIVE PROCESSESDisclaimer: Please note that ProviderConnect SM may look different and have different functionalities based on individual

contract needs, therefore some functions may not be available or may look different for your specific contract.


ProviderConnect Benefits

What are the benefits of ProviderConnect?• Free and secure online application.

• Access routine information 24 hours a day, 7 days a week

• Complete multiple transactions in single sitting

• View and print information

• Reduce calls for routine information

• Smartphone/Mobile Device Friendly

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How to Access ProviderConnect

Go to www.ValueOptions.com, choose “Providers”

In-network providers can self register for using provider ID number

Multiple logons from same provider ID number available• Fax completed Provider Services Account Request Form to

1-866-698-6032

Contact Information:• ValueOptions EDI Helpdesk • 1-888-247-9311 • [email protected]• Monday to Friday, 8:00 a.m. - 6:00 p.m. ET

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ProviderConnect® Login Screen

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User Agreement Page

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Search/View Member Eligibility

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ProviderConnect Message Center (Personalized!)

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Inquiry Details

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Message Center - Parity

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Message Center – Threshold Claim

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Outpatient Outlier Request for Information

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Message Center – Treatment Guideline Notification

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Request for Clinical Information Response Process

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Enter or Review an Authorization

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Search Authorizations

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Authorization Search Results

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Authorization Summary

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Authorization Detail

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Recent Authorization Letters

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New Authorization Letters

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Direct Claim Submission

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EAP Case Activity and Billing Form on ProviderConnect

Network providers authorized to perform EAP services can now submit their one-page version of the CAF-1 billing forms via. ProviderConnect

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View Provider Summary Voucher

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Provider Summary Voucher Results

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Provider Summary Voucher Sample

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My Online Registration Profile

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Updating My Online Profile

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On Track Outcomes

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Role-Based Security: Features

New level of ProviderConnect access to enhance security as required by HIPAA guidelines

Level of ProviderConnect access defined by role

Roles defined by user type and/or VO business rules

Users assigned roles with access to certain functions

i.e. claims

User Types: Super User, Managed User (managed by Super User), Standard User

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NETWORKCONNECTSM

Robust network management and provider relations

CARECONNECTSM

Superior clinical case management and data collection

SERVICECONNECTSM

Industry-best customer service and issue resolution

MEMBERCONNECTSM

Online self-service and award-winning content for members

TELECONNECTSM

Easy-to-access telephonic self-service for providers and members

PROVIDERCONNECTSM

Secure, online administrative self-service for providers

ValueOptions Connect System

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ProviderConnect Training Webinars

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Scheduled monthly

Topics include: Authorizations, Claim Submission, Role-based security, Re-credentialing, Viewing Patient Info, etc.

Webinar calendar available at http://www.valueoptions.com/providers/Providers.htm• Next webinar scheduled for 10/9/13


Video Tutorial Library

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The library includes tutorials on how to:• Navigate ValueOptions.com

• Navigate ProviderConnect

• Navigate the Provider Handbook

• Locate the most recent version of the Provider newsletter

Video tutorials are located at the following link:• http://www.valueoptions.com/providers/How-To.htm

Additional video tutorials will be posted throughout 2013!


Overview of Operational Areas


ValueOptions National Network Services

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Provider Relations• Ensures members’ behavioral health care needs are met

through a geographically and clinically robust network of providers

• Ensures maintenance of network composition by engaging in assertive retention strategies;

• Engages in timely and appropriate recruitment

• Engages in professional, consistent, and educative communications with provider community and staff

Provider Credentialing• Completion of Credentialing Application required for

network participation



Provider Recredentialing (every 3 years)

Notifications• 4 months prior to due date (telephonic), 1 week later (email/fax), 15

and 30 days prior to due dateFailure to respond to requests will result in disenrollment from the network

Process• Complete online, prepopulated recredentialing application

• Attach updated license, certification and malpractice information

• Electronically sign the application (once signed, it is automatically submitted)

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Provider Contracting

• ValueOptions Provider Agreements


Questions about Contracting and Credentialing?

Call 1-800-397-1630

(8am – 5pm ET)

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ValueOptions Quality Management

Quality Management Program Oversight provided by Medical Director

Key Quality Indicators include but are not limited to:• Satisfaction Survey measures

• Access/Availability of Services – geographic access, phone statistics, appointment availability, etc.

• Complaints/Grievances - tracking and reporting

• Patient Safety – adverse incidents and quality of care

• Coordination of Care

• Quality Improvement Activities/Projects

• Compliance with URAC and NCQA Standards

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ValueOptions Quality Management (cont.)

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Ongoing Quality Improvement Activities (QIAs)• Clinical QIAs

• Ambulatory Follow-up Time in the Comm unity – Depression Management

Risk Tracking – Referral for Urgent and Emergent Treatment

• Service QIAs Average Speed of Answer

Provider Satisfaction with Utilization Management


Electronic Claims Submission

Advantages: • Better, faster, and cheaper

• Reduced Paper Files

• Reduced Labor and Postage Expenses

• Reduced potential of error or mishandling

• Faster claims processing improves cash flow

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ValueOptions EDI (Electronic Data Interchange)

Accept claims files from any Practice Management System outputting HIPAA formatted 837P or 837I files, and from EDI claims submission vendors

Offer Direct Claims Submission on website to providers who do not have own software or who wish to submit certain claims outside their batch files• These claims are processed immediately, and you are provided the

claim number.

• You may submit batch claims files or Direct Claims interchangeably.

No charge for electronic claims submission

Access to support:• http://www.valueoptions.com/providers/Provider_Connect.htm

• Helpdesk: 1-888-247-9311 between 8am - 6pm ET

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ICD - 10

ValueOptions is preparing for the 10th modification to International Classification of Diseases (ICD) codes

• Will be compliant with regulation and only accept ICD-10 codes on or after the official compliance date confirmed by CMS to be October 2014

• Will cease to accept ICD-9 codes following the time parameters of the regulation.

• All providers should read the latest ICD-10 Frequently Asked Questions (FAQs) at http://www.valueoptions.com/providers/Files/pdfs/ICD-10_FAQ.pdf

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Customer Service Philosophy

Committed to providing our members and providers with the most accurate and informed benefit, eligibility, claims, and certification information in the most effective, efficient, and compassionate manner

Puts our members’ needs and concerns first and is committed to resolving inquiries promptly without the need to make a re-contact

We value our members’ questions and concerns and place member satisfaction at the heart of our Customer Service philosophy

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Key Areas of Expertise

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Referred by Health Plan Care Manager

Referred From Employer EAP Provider

Key Components of the ValueOptions®

Care Management Paradigm• Authorization and care management recommendations

are Individualized for Diagnoses and Level of Care requests.

• Collaborative approach with treating providers.

• Symptom Complex based review processes.

• Utilization of treatment guidelines, Level of Care criteria and treatment algorithms.

• Intensive Care Management programs for high risk high cost members.

• Intensive Care Management activities to impact:

Acute Inpatient

Residential

Partial Hospital

• Special protocols based on client nuances.

Members Who Seek Care Via the ValueOptions®

Clinical Referral Line

Members Identified By Health Plan Disease

Management Screening

Members Identified By Predictive Modeling

Software – High Risk Physical Potential

Co-morbid Behavior

Members Entering the Behavioral Health System

In Crisis

Members Identified As High Risk (Multiple

Channels)

Members Identified By ValueOptions®

PharmaConnect Application

Care Management Paradigm


Referral Assistance

Licensed care management staff is available 24 hours a day/seven days a week for referral and utilization management• Member referral process:

Emergencies are followed until disposition

Urgent referrals are offered appointments within 48 hours and are called to ensure appointment is kept

Providers can contact ValueOptions for referral assistance if needed

Providers should contact ValueOptions 24 hours a day/seven (7) days a week if members require higher level of care or increased visit frequency

Care Management staff will assist with referral to inpatient or specialty programs

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Utilization Management Process

Inpatient• Requests are completed via the web or telephonically by calling the

number on the back of the members Identification card

• Some clients still require pre-authorization for HLOC – notification requirements may also vary

• ValueOptions staff are available 24 hours a day/ seven (7) days a week

Outpatient• Since pass through or registration no longer applies to outpatient

services impacted by federal parity, authorization cannot be required

Not all clients are subject to federal parity

It is important to check benefits and authorization requirements on each member via the web or by calling the number on the member’s identification card.

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Utilization Management Process

Outpatient

• Outpatient care management will be conducted primarily through front-end claims or claims extracts, and will emphasize 4 areas:

Complex Diagnoses

Outlier cases

Outlier Providers

Intensive Care Management

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Resources for Providers

Clinical information on www.valueoptions.com:

• ValueOptions Medical Necessity criteria

• Changes to Substance Use Medical Necessity Criteria

• Treatment Practice guidelines

• PCP consult line 9 am to 5 pm (Eastern Time)

• Intensive Case Management Services

• PharmaConnect analyzes pharmacy data and uses automated rules engine to screen for:

Sub-optimal therapy

Under-use

Early discontinuation

Automatic notification to providers

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Resources for Providers (cont.)

Clinical information: www.valueoptions.com:

• Health Alert

• Federal Mental Health Parity

• On Track

• Achieve Solutions®

• a continuously updated and trusted behavioral health and wellness Web site that you can share with your patients. Designed with an intuitive, user-friendly interface, the site provides more than 6,000 articles on over 200 topics

• Outpatient Detoxification/Buprenorphine (Suboxone® or Subutex® ) Maintenance Program

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Medical Necessity Criteria Changes

On January 1, 2013, ValueOptions revised the structure for Substance Use Medical Necessity Criteria and will no longer follow the American Society for Addiction Medicine (ASAM) Patient Placement Criteria for the Treatment of Substance – Related Disorders

Providers can access the revised Substance Use Medical Necessity Criteria via the Provider Handbook page

• http://www.valueoptions.com/providers/Handbook/clinical_criteria.htm

Reference the Network Specific Site to see whether a Network Specific Contract requires the use of ASAM Criteria

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DSM-5

In May, the American Psychiatric Association (APA) released the new DSM-5.

The APA is recommending all insurance companies have DSM-5 implemented by January 1, 2014.

ValueOptions will be adopting the DSM-5 coding for clinical purposes and will be working towards the APA deadline.

Additional details around the migration to DSM-5 will be released on our website as it becomes available.

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Stamp Out Stigma (S.O.S.) Campaign

S.O.S. encourages individuals to talk to friends and loved ones about mental illness to show commitment to stamping out stigma of mental illness.

The campaign is now being introduced to our provider community to further support our valued providers when communicating with patients about mental illness.

A provider toolkit is available online for our providers to access S.O.S. materials.

Visit our provide page to learn more about S.O.S.

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Provider Contacts

Provider Relations, Credentialing and Contracting Questions:

• 1-800-397-1630 (8 am - 5 pm ET Monday - Friday)

Electronic Claims & ProviderConnect Technical Questions (EDI Help Desk):

• 1-888-247-9311 (8 am - 6 pm ET Monday - Friday)

• [email protected]

For PaySpan Registration Provider Support contact:

• 1-877-331-7154

• [email protected]

Provider Support is available from 8am to 8pm Eastern time, Monday through Friday

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Featured Presentation: Fraud Waste & Abuse

2013


Questions?

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ValueOptions Program

Integrity

September 2013

1

Topics for Today’s Presentation

• Development of Program Integrity, Laws & Requirements

• Current Audit Activities

• Preparing for an Audit

• Basic Documentation Requirements

2

Key Terms

Fraud – Intentional deception or misrepresentation

made by a person with the knowledge that the

deception could result in some unauthorized benefit.

• Many payment errors are billing mistakes and are not the result of

someone such as a physician, provider, or pharmacy trying to take

advantage of the Medicaid Program.

• Fraud occurs when someone intentionally falsifies information or

deceives the Medicaid Program.

3

Key Terms (cont.)

• Waste – Thoughtless or careless expenditure, consumption, mismanagement, use or squandering of healthcare resources,

including incurring costs because of inefficient or ineffective

practices, systems or controls.

• Abuse – Provider practices that are inconsistent with sound

fiscal, business or medical practices, and result in an

unnecessary cost to health programs, or in reimbursement for

services that are not medically necessary or fail to meet

professionally recognized standards.

4

Key Terms (cont.)

• Compliance Program – Systematic procedures instituted to ensure that contractual and regulatory requirements are being met.

• Compliance Risk Assessment – Process of assessing a company’s risk related to its compliance with contractual and regulatory requirements.

• Compliance Work Plan – Prioritization of activities and resources based on the Compliance Risk Assessment findings.

• Program Integrity – Steps & activities included in the compliance program & plan specific to fraud, waste & abuse.

5

Program Integrity, Laws &

Requirements

6

History of Program Integrity

• Balanced Budget Act (BBA)

– Amended Social Security Act (SSA) re: Healthcare Crimes

– Must exclude from Medicare & state healthcare programs those convicted of healthcare offenses

– Can impose civil monetary penalties for anyone who arranges or contracts with excluded parties

• Federal False Claims Act (FCA)

– Liable for a civil penalty of not less than $5,000 & no more than $10,000, plus 3x amount of damages for those who submit, or cause another to submit, false claims

• Deficit Reduction Act (DRA)

– Requires communication of policies & procedures to employees re: FCA, whistleblower rights and fraud, waste & abuse prevention, if receiving more than $5M in Medicaid

7

History of Program Integrity (cont.)

• 7 Basic Elements of a Compliance Program as Adopted by OIG & CMS (based on Federal Sentencing Guidelines)

– Written policies & procedures

– Compliance Officer & Compliance Committee

– Effective training & education

– Effective lines of communication between the Compliance Officer, Board, Executive Management & staff (incl. an anonymous reporting function)

– Internal monitoring & auditing

– Disciplinary enforcement

– Mechanisms for responding to detected problems

8

Regulatory Changes = Heightened

Federal & State Awareness

• Laws & regulations are now formalizing & emphasizing the effectiveness in prevention, detection & resolution of fraud, waste & abuse as well as the recovery of overpayments.

• Fraud Enforcement and Recovery Act of 2009 (FERA)

• Patient Protection and Affordable Care Act (PPACA – Healthcare Reform Act)

• Per Federal regulations, providers excluded from one line of business with ValueOptions, will not be able to participate in

any ValueOptions network or lines of business

• ValueOptions required to check Federal exclusion lists regularly to make sure no excluded providers are in network

•

9

New 8th Element of a Compliance

Program

• Compliance Programs Must be Effective

– Must show that compliance plans are more than a piece of paper

– Must be able to show an effective program that signifies a proactive approach to the identification of fraud, waste & abuse

– How much fraud, waste & abuse have you identified?

– How much fraud, waste & abuse have you prevented?

10

Current Audits and

Enforcement Entities

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Types of Audits

12

• Compliance Audit Evaluates strength and thoroughness of compliance

preparations.

• Program Integrity Audit Evaluates strength and thoroughness of efforts to prevent,

detect and correct Fraud and Abuse.

Federal Level Activities – Centers for

Medicare & Medicaid Services

(CMS)

• Medicaid Integrity Program (MIP)

• Medicaid Integrity Group (MIG)

• Medicaid Integrity Contractors (MIC)

13

MIC Auditors by Region • New York (CMS Regions I & II)

– Island Peer Review Organization (IPRO)

• Atlanta (CMS Regions III & IV)

– Health Integrity, LLC

• Chicago (CMS Regions V & VII)

– Health Integrity, LLC

• Dallas (CMS Regions VI & VIII)

– Health Management Systems (HMS)

• San Francisco (CMS Regions IX & X)

– Health Management Systems (HMS)

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MIC Jurisdictions/Regional Offices

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New York: Regions 1,2

Atlanta: Regions 3,4

Dallas: Regions 6,8

Chicago: Regions 5,7 San Francisco:

Regions 9,10

Also: CNMI, Guam, American

Samoa

15

Other Enforcement Entities

• U.S. Department of Health & Human Services, Office of Inspector General (OIG)

• U.S. Department of Justice (DOJ)

• Office of the State Attorney General (AG) – Medicaid Fraud

Control Unit (MFCU)

• Federal Bureau of Investigation (FBI)

• Department of Insurance (DOI)

16

Prepare, You Will be

Audited

17

How Do We Do This?

• Use the 8 Elements of an Effective Compliance Program as a Guide

• Delegate a Knowledgeable Point Person

• Know Your Contractual & Regulatory Requirements re: Fraud, Waste &

Abuse

• Educate Staff on How Daily Activities Prevent, Detect & Address Fraud,

Waste & Abuse.

– https://oig.hhs.gov/compliance/101/index.asp

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Establish an Environment of

Awareness • Provide clinically necessary care through services within the

scope of the practitioners’ licensure

• Routinely monitor treatment records for required standardized

documentation elements

• Monitor & adhere to claims submission standards

• Correct identified errors

• Hold staff accountable for errors

• Cooperate w/ all audits, surveys, inspections, etc.

• Cooperate w/ efforts to recover overpayments

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Establish an Environment of

Awareness (cont.) • Maintain documentation of all P&Ps, activities, audits,

investigations, etc.

• Verify member eligibility

• Ensure staff know how to report fraud, waste & abuse

• Communicate internally & externally

• Set-up a suggestion box for anonymous concerns and suggestions for improvement

• Post fraud, waste & abuse tips

• Send out weekly tips on how to prevent fraud

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Conduct Self-Assessments

• Detail All Program Integrity Requirements &

Contract Requirements

• Assess & Prioritize Gaps in Compliance & Develop

Action Plans to Remedy = Document All Efforts

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Conduct Self-Assessments (cont.)

Ask Yourselves Assessment Questions regarding:

– Identification of employees who lost credentials

– Meeting standards to ensure treatment record documentation

– Accurate billing and documenting for services rendered

– Routine checking of member eligibility

– Training of staff

– Ability to anonymously report internal fraud, waste and/or abuse

concerns?

– Effectiveness of current processes

22

Train Staff to Recognize Fraud, Waste

& Abuse • Common Fraud Schemes:

– Billing for “Phantom Patients”

– Billing for Services Not Provided

– Billing for More Hours than In a Day.

– Using False Credentials.

– Double-Billing

– Misrepresenting diagnosis, type/place of service, or who rendered service

– Billing for non-covered services

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– Upcoding

– Failure to collect co-insurance/deductibles

– Inappropriate documentation

– Lack of computer integrity

– Failure to resolve overpayments

– Delays in discharge to run up bill

– Kickbacks

Train Staff to Recognize Fraud, Waste

& Abuse

• Common Member Fraud Schemes:

– Forgery

– Impersonation

– Co-Payment Evasion

– Providing False Information

– Sharing or theft of Medicaid benefits

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Basic Documentation

Requirements “If It’s Not

Documented – It Didn’t

Happen”

25

Purposes for Documentation

• Provides Evidence Services Were Provided

• Required to Record Pertinent Facts, Findings, & Observations about an Individual’s Medical History, Treatment, and Outcomes

• Facilitates Communication & Continuity of Care Among Counselors & Other Health Care Professionals Involved in the Member’s Care

• Facilitates Accurate & Timely Claims Review & Payment.

• Supports Utilization Review & Quality of Care Evaluations

• Enables Collection of Data Useful for Research & Education

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ValueOptions’ Approach to Program

Integrity: Prevention

ValueOptions attempts to prevent paying for billing errors through the following ways:

• Being an Industry Partnership

• Training & Education

• Provider Support

• Contractual Provisions

• Provider Profiling & Credentialing

• Ethics Hotline

• Claims Edits

• Prior Authorizations

• Member Handbook

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ValueOptions Provider Handbook

and Contract

• The provider handbook is an extension of the provider contract and includes guidelines on doing business with

ValueOptions, including policies and procedures for individual

providers, affiliates, group practices, programs and facilities.

• Together, the provider agreement, addenda, and handbook

outline the requirements and procedures applicable to

participating providers in the ValueOptions network(s)

Except to the extent a given section or provision in the handbook is included to address a regulatory, accreditation or

government program requirement or specific benefit plan requirement, in the event of a conflict between a member’s benefit

plan, the provider agreement and the handbook, such conflict will be resolved by giving precedence in the following order: (1)

the member’s benefit plan, (2) the provider contract and (3) the handbook.

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Additional Documentation

Standards

• State regulations and/or disciplinary standards may also have an impact on documentation standards

• Be sure to check your state regulations and licensing

standards for any additional requirements

29

Code of Conduct

• The ValueOptions Code of Conduct was created pursuant to State and Federal requirements.

• Providers should read the code of conduct and comply with

the parts that are applicable to their line of business.

30

ValueOptions’ Approach to Program

Integrity: Detection

• Audit & Detection

– Internal/External Referral Process

– Audits

– Post-Processing Review of Claims

– Data Mining & Trend Analysis

– Special Reviews

• Investigation & Resolution

– Investigation & Disciplinary Processes

– Reporting Requirements

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Basic Documentation Needs

• All billable activities must have a start & stop time

• Service codes used in claims for payment must match codes used in charts

• Detailed progress notes for members

• Number of units billed must match number of units in documentation

• Full signatures with credentials & dates on all documentation

• Covered vs. non-Covered services

• Services provided/documented meet service definition for code billed

• Progress notes are legible and amendments clearly marked

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Documentation – Additional Tips

• Activity Logs Should Not be Pre-Signed

• Progress Notes Must be Written After the Group/Individual

Session

• All Entries Should be in Blue or Black Ink for Handwritten Notes,

Not Pencil, No White-Out

• Keep Records Secure and Collected in One Location for Each

Member

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1. Referral received

2. Referral reviewed and charts may be ordered

3. Providers required to supply copies of the charts requested

within specified timeframes

4. Charts will be reviewed by VO staff

5. After completion of the review, results letter will be sent to the provider

VO Provider Audits

Common Errors Found by VO staff

• Not submitting all documentation requested

• Wrong date of service submitted on the claim

• Provider rendering the service was different than

the provider billing the service

• Nothing documented on the weekends for

residential services

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ValueOptions Contact & Reporting

Info

• ValueOptions Ethics Hotline

– 1-888-293-3027

• Report Concerns to Your Organization’s Compliance Office, ValueOptions directly, or via ValueOptions’ Ethics Hotline

– Remember: you may report anonymously and retaliation is prohibited when you report a concern in good faith

– Reporting all instances of suspected fraud, waste and/or abuse is an expectation and responsibility for everyone

• If Available, Report to Your State’s Medicaid Fraud and Abuse Control Unit (MFCU)

36

Laws Regulating Fraud, Waste & Abuse • False Claims Act (FCA), 31 U.S.C. §§ 3729-3733

• Stark Law, Social Security Act, § 1877

• Anti-Kickback Statute, 41 U.S.C

• HIPAA, 45 CFR, Title II, § 201-250

• Deficit Reduction Act (DRA), Public Law No. 109-171, § 6032

• Care Programs, 42 U.S.C. § 1128B, 1320a-7b

• False Claims Whistleblower Employee Protection Act, 31 U.S.C. §

3730(h)

• Administrative Remedies for False Claims and Statements, 31 U.S.C. Chapter 8, § 3801

37

Program Integrity Links • Code of Federal Regulation:

– TITLE 42-Public Health, Chapter IV-CMS, DHHS, SUBCHAPTER C-Medical Assistance Programs, Part 455-Program Integrity: Medicaid.

– www.gpoaccess.gov/cfr/index.html

• Office of Inspector General (OIG):

– www.oig.hhs.gov/fraud.asp

• Center for Medicare and Medicaid Services (CMS):

– www.cms.gov/MedicaidIntegrityProgram/

• National Association of Medicaid Fraud Control Units (NAMFCU):

– www.namfcu.net/

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http://www.gpoaccess.gov/cfr/index.html

http://www.oig.hhs.gov/fraud.asp

http://www.cms.gov/MedicaidIntegrityProgram/

http://www.namfcu.net/

Questions & Answers

39

Thank You

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Documents

Giving Value Back to the Provider - Beacon Health Options · Committed to principles of recovery and resiliency Diverse client base • Commercial Division ... Free Internet based