NC Department of Health and Human Services DMA MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSW Chief,

NC Department of Health and Human Services medicaidnorthcarolinamedicaid

northcarolina

DMA

MH/IDD/SA Providers working in a

Medicaid Managed Care Environment

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

Program IntegrityMarch 7, 2012


northcarolina

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)


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DMA

Program Integrity

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

• The Division of Medical Assistance has approximately 74,000 providers

• The Current number of eligible Medicaid recipients is 1.5 million and Health Choice is approximately 130,000 recipients.

• Over 9,000 Behavioral Health Providers


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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”

----Dr. Craigan Gray, MD, JD, Director, NC DMA


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DMA

Program Integrity

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

Program Integrity

Governor’s Initiatives to address Medicaid fraud and abuse:

• Signed Senate Bill 675, Prohibit Medicaid Fraud/ Anti-Kickback law (Session Law 2010-185)• Increased technology to detect and prevent Medicaid fraud and

abuse• Allocated staff to increase on-site investigations• Campaigned to encourage the public and providers to report

suspected Medicaid fraud and abuse• Increased staff in the Prosecution Unit of Medicaid Investigation

Unit-Attorney General’s Office to handle Medicaid fraud and abuse cases


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DMA

Program Integrity

Public Concern

• Fraud and abuse takes money from needy children, the elderly, blind, and disabled. Therefore, identifying, investigating, preventing and recovering money billed improperly to Medicaid is an important mission for this agency

• Cost taxpayers millions of dollars


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DMA

Program Integrity

Public Concern

The majority of providers and their billings are honest and accurate. However, one dishonest provider can take thousands of dollars slowly over time by billing for services not rendered or medically unnecessary.


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DMA

MCO Responsibilities

MCOs 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• Credentialing and re-credentialing requirements

– Policy & procedures– Process– Nondiscriminatory: high risk specialize in conditions that requires

costly treatment– Excluded providers


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MCO Responsibilities:

• Monitor providers regularly to determine compliance

• Take corrective action if there is failure to comply

• Mechanism to detect both utilization and overutilization of services

• Mechanism to assess the quality and appropriateness of care

• Make sure providers are credentialed


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Provider Screening & Enrollment:• Deny enrollment any person with a 5% or greater direct or

indirect ownership interest in the provider– Did not submit timely and accurate information and cooperate

with screening– Has been convicted of a criminal offense related to that persons

involvement with Federal Health Care program in at least 10 years

– Fails to submit sets of fingerprints within 30 days of DMA/CMS request

– Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visit


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Provider Screening & Enrollment

• Verify license

• Confirm that license has not expired

• Revalidate the enrollment of all providers at least every five years


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Provider Screening & Enrollment:

• Must terminate or deny enrollment if the provider fails to permit access to provider locations for any site visit

• Must conduct pre-enrollment and post enrollment site visits of providers who are designated as moderate or high categorical risks to the Medicaid program

• Must require providers to consent to criminal background checks


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Provider Screening & Enrollment

• Must check all available Federal databases-determine the exclusion status of providers (Social Security Administration’s Death Master File, the National Plan and Provider Enumeration System (NPPES), the List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS), and any other such database the Secretary may prescribe.


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Provider Screening & Enrollment (limited, moderate, or high)

Limited risk. • Verify provider meets all applicable Fed and State

requirements• Conduct license verification• Conduct database checks (pre- and post-enrollment)

Moderate risk: • All of the Limited screening requirements and• Conduct on-site visits


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Provider Screening & Enrollment High risk: • must do limited and moderate screening requirements • conduct a criminal background check, and • require the submission of finger prints

The adjustment of categorical risk levels must happen when a payment suspension is imposed based on credible allegation of fraud, waste or abuse, existing Medicaid overpayment or provider been excluded by the OIG or another states Medicaid program within the previous ten years


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Provider Responsibilities

• Meet enrollment criteria & needs of the MCO• Be in Good standing with Federal and State Agencies

(DMA, DMHDDSAS, DHSR, DOL, DOR, IRS, etc)• Not on the OIG exclusion list or any other State

exclusion list• Comply with all Federal and State regulations• Develop corporate compliance plan• Conduct regular QA activities and self audits


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Provider Responsibilities

• Submit claims that are proper and provide services that are medically necessary

• Offer training on fraud, waste, and abuse and mechanisms to report incidents or complaints

• Improve standard of care for consumers• Help identify gaps in services and needs of the

community served• Participate in collaborative efforts to move the

managed care delivery system forward


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DMA

Program Integrity

Provider Abuse

10A NCAC 22F .0301Provider abuse includes any incidents, services, or practices inconsistent with accepted fiscal or medical practices which cause financial loss to the Medicaid program or its beneficiaries, or which are not reasonable or which are not necessary


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Program Integrity

Provider Fraud

Individual participating or non-participating providers who deliberately submit claims for services not actually rendered, or bill for higher-priced services than those actually provided.

Providers submission of claims for payment for which there is no supporting documentation available.


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Program Integrity

CONFIDENTIALITY

10A NCAC 22F .0106All investigations by the North Carolina Division of Medical Assistance concerning allegations of provider fraud, abuse, over-utilization, or inadequate quality of care shall be confidential, and the information contained in the files of such investigations shall be confidential…


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DMA

Program Integrity

Trends in Behavioral Health:

• Overutilization of behavioral health services.

• Billing for care and services that are provided by an unauthorized, unqualified, or unlicensed person.

• Limiting access to services

• Denying access to services


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Program Integrity


• Diagnosis does not correspond to treatment rendered

• Failure to provide and maintain:– proper quality of care,– appropriate care and services, or– medically necessary care and services.

• Breach of the terms and conditions of participation agreements, or a failure to comply with requirements of certification, or failure to comply with the provisions of the claim form.


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DMA

Program Integrity


• Altered signatures on documentation• “Canned Notes”• Double billing• Excessive use of CPT or H Codes• Billing for services not rendered• Billing for excessive recipients per workday• Excessive billing beyond a 24 hour period


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DMA

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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DMA

Program Integrity

False Claims

Under this Act, 31 U.S.C. Chapter 8, §3801, any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim.


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Program Integrity

Credible Allegation of Fraud

42 CFR 455 – New Federal Rules, March 25, 2011

Credible Allegations of Fraud – Suspension of Medicaid payments


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DMA

Program Integrity

• A credible allegation of fraud may be an allegation, which has been verified by the State, from any source, including but not limited to the following:– Hotline Complaint– Data Mining– Patterns identified through provider audits, civil false

claims cases, and law enforcement investigations.


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DMA

Program Integrity

• DMA must suspend all Medicaid payments to a provider after the agency determines there is credible allegation of fraud for which an investigation is pending under the Medicaid program against an individual provider or entity unless the agency has good cause to not suspend payments or to suspend payment only in part.


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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• Two to three days depending on the complaint/issue • Entrance Conference, fact finding, and exit conference• Administrative Action• Reconsideration Review, Contested Case hearing, Superior Court• Findings of an investigation may be referred to the Attorney

General’s Office• The State’s AG’s office 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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Sanctions & Remedial Measures

• Termination of provider’s participation• Withholding Payments• Recoup overpayments• Warning Letters• Suspension of a provider for a period of time• Probation • Prepayment Claims Review• Provider Lock-out


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Other Things to consider:

• Designate someone to be your compliance officer

• Develop a corporate compliance plan

• Training & education for the compliance officer and organization employees on fraud, waste, and abuse

• Lines of communication between compliance officer and the organization employees

• Topics to cover: criminal background checks, OIG Exclusions list, professional conduct and ethics, Changes in license status, when to report, etc.


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DMA

Program Integrity

Fraud and Abuse Reporting (Provider):

• Local Managed Care Organizations (LME-MCOs)• Contact the Division of Medical Assistance by calling the DHHS

Customer Service Center at 1-800-662-7030 (English or Spanish) or; • Call the Medicaid fraud, waste and program abuse tip-line at 1-877-

DMA-TIP1 (1-877-362-8471); or • Call the Health Care Financing Administration Office of Inspector

General's Fraud Line at 1-800-HHS-TIPS; or • Call the State Auditor's Waste Line: 1-800-730-TIPS; or • Complete and submit a Medicaid fraud and abuse confidential onlin

e complaint form at: http://www.ncdhhs.gov/dma/fraud/reportfraudform.htm

http://www.ncdhhs.gov/dss/local/index.htm

http://www.ncdhhs.gov/dss/local/index.htm

http://www.ncdhhs.gov/dma/fraud/index.htm


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Program Integrity

Fraud and Abuse Reporting (Recipient):

• Local Managed Care Organization (LME-MCOs)• Call your County Department of Social Services (DSS) office;

or • Contact the Division of Medical Assistance by calling the

DHHS Customer Service Center at 1-800-662-7030 (English or Spanish) or;

• Call the Medicaid fraud, waste and program abuse tip-line at 1-877-DMA-TIP1 (1-877-362-8471); or

• Complete and submit a Medicaid fraud and abuse confidential online complaint form at: http://www.ncdhhs.gov/dma/fraud/reportfraudform.htm

http://www.ncdhhs.gov/dma/fraud/reportfraudform.htm



http://www.ncdhhs.gov/dma/fraud/index.htm


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QUESTIONS or COMMENTS

CONTACT:

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

NC DMA – Program IntegrityPhone: (919) 647-8049

Fax: (919) 647-8054Email: [email protected]

mailto:[email protected]

Documents

NC Department of Health and Human Services DMA MH/IDD/SA Providers working in a Medicaid Managed Care Environment Patrick O. Piggott, MSW, LCSW, DCSW Chief,