OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION State Program Update Panel PHA Annual Conference Laurie Rock Pamela

OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011OFFICE OF ADMINISTRATION

State Program Update PanelPHA Annual Conference

Laurie RockPamela MaileyMay 17, 2012


• Explain the Bureau of Program Integrity responsibilities

• Discuss Medical Assistance regulatory requirements

• Discuss relevant elements of Affordable Care Act

• Providers’ responsibility to screen employees

• Common review findings

• Questions

Discussion Points


Bureau of Program Integrity

Federally mandated function to:

• Prevent, identify and combat fraud, waste and abuse within the Medical Assistance program

• Monitor providers’ compliance with Medical Assistance regulations and requirements

• Ensure Medical Assistance recipients receive quality care and do not abuse their benefits

OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011

Presentation Title

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OFFICE OF ADMINISTRATION


Responsibilities include:

• Evaluate services and claims for compliance

• Monitor recipient overuse or abuse of services

• Refer to civil and criminal agencies

• Enforce administrative actions

• Conduct outreach and education



Fraud • an intentional deception or misrepresentation made by a person with the

knowledge that the deception could result in some unauthorized benefit to that person or some other person

Abuse • provider practices that are inconsistent with sound fiscal, business, or

medical practices, and result 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 for health care

Waste• not currently defined in federal Medicaid regulations• generally understood to encompass the over-utilization or inappropriate

utilization of services and misuse of resources, and typically is not a criminal or intentional act


Regulations and Other Instructions

Federal • Program integrity – 42 CFR Part 455• Utilization control – 42 CFR Part 456

State – 55 PA Code• Chapter 1101 – General Provisions• Chapter 1150 – Payment Policies• Chapter 1130 – Hospice• Chapter 1249 – Home Health

MA Provider Bulletins• 37-02-01 – findings from hospice reviews

Provider Handbooks/Billing Instructions


Regulations

General Provisions – 55 PA Code §1101

• These regulations apply to all enrolled providers• Based on state and federal laws

Some important sections include:

55 Pa Code §1101.51 (e) – records must:

• Medical and fiscal records must disclose nature and extent of services

• Contain documentation of medical necessity of ordered, rendered and prescribed services

• Be available for review/copying

• Be retained for a minimum of 4 years


Regulations


55 Pa Code §1101.75 (a) and (b) – Provider prohibited acts:

• Violations of these are the most serious

• Some violations are considered criminal acts subject to investigation and prosecution by Medicaid Fraud Control Unit

• Subject to enforcement actions by DPW and restitution


Regulations


55 Pa Code §1101.66 – Compensable services – must be:

• Medically necessary

• Not in excess of need

• Not solely for recipient convenience

• No payment for services or items by providers terminated from the Medical Assistance program


Affordable Care Act

Level of screening will depend on risk of fraud, waste, & abuse

• Limited risk Verify compliance with applicable federal and/or state requirements License verification Database checks – e.g. EPLS, LEIE, SSI master death file

Moderate risk (includes hospice organizations) All limited risk requirements and On-site visits – pre- and post enrollment

High risk (includes newly enrolling home health and DME suppliers) All limited and moderate risk requirements and Conduct criminal background checks and fingerprinting (states not

required to implement until additional guidance is issued)

Provider Enrollment Screening


Affordable Care Act

• Adjustment of risk levels

• Level of risk must move to high if a payment suspension is imposed (based on credible allegation of fraud)

• Level of risk must move to high if provider has been excluded in the past 10 years

• Level of risk must move to high for 6 months following any temporary enrollment moratoria

• MA may rely on results of screening from:

• Medicare contractors

• MA or CHIP agencies from other states

• Revalidation – States must revalidate all enrolled providers every 5 years


• Compliance Programs

• HHS is required to establish compliance program requirements and timeline for establishment of core elements.

• Compliance program is a condition of enrollment for Medicare, Medicaid, and CHIP providers and suppliers.

• Enrollment and NPI of Ordering or Referring Providers

• All ordering and referring physicians and other professionals under the State plan or waiver program must be enrolled in Medicaid as a participating provider.

• NPIs must be on all claims for payment of ordering and referring physicians and other professionals.

Affordable Care Act


Reporting and Returning Overpayment

• Providers, suppliers, Medicaid MCOs, Medicare Advantage plans, and PDP sponsors must report and return overpayments to HHS, the State, or a Medicare intermediary or carrier by the later of:• 60 days of identification of overpayment, or • the due date of the cost report.

• Treble damages and CMPs up to $50K for knowing failure to return overpayments on time.

• Knowing and failure to report may also be considered a false claim under the Federal False Claims Act.

Affordable Care Act


Payment Suspension/Credible Allegation of Fraud

• HHS may suspend and the State must suspend payments to individuals or entities based upon credible allegations of fraud, unless HHS/the State determines there is good cause not to suspend payments.

• Applies to Medicare and Medicaid.

Affordable Care Act


Face to Face Encounters

• Proposed rules for Medicaid issued July 12, 2011 (42 CFR part 440)• Must occur and be documented 90 days prior or 30 days after order for

home health or DME (for Medicaid)• Can be done by a physician or non-physician practitioner

• Nurse• Nurse practitioner• Clinical nurse specialist • Certified nurse midwife (not allowable for DME)• Physician assistant

• However, documentation of the face-to-face encounter is the physician’s responsibility

Affordable Care Act


Recovery Audit Contractor Program

The State must establish a RAC Program consistent with State law by 1/1/12.

RAC must identify overpayments and underpayments.

The State must pay RACs on a contingency fee basis for recoveries of overpayments.

State appeals procedures must apply.

RACs must coordinate with other reviewing entities and law enforcement.


Medical Assistance Bulletin 99-11-05

Provider Screening of Employees and Contractors for Exclusion and Effect of Exclusion

• 42 CFR 1001.1901 (b) - ”no payment will be made by Medicare, Medicaid, or any other Federal Health Care program for any item or service furnished, by an excluded individual or entity, or at the medical direction or on the prescription of a physician or other authorized individual….”

• Providers should screen monthly

• Sources to use for screening checks:• PA Medicheck List• List of Excluded Individuals/Entities (LEIE) – federal listing• Excluded Parties List System (EPLS)


Hospice Reviews

Include review of:

• Hospice care

• Pharmacy

• DME

• Inpatient services

• Home health services


Common Violations


• Lack of Medical Necessity

• Inappropriate Level of Care/Services

• Inappropriate Revocations


• Missing/Incomplete MA 372 Certification of Terminal Illness Form

• Election of Hospice Form MA 373 not completed

• Incomplete Records

Current Findings/violations are consistent with past review periods.

Record Keeping Violations


Questions


Contact Information:

Laurie RockDirectorBureau of Program Integrity

[email protected]

Pamela MaileyDirector Division of Program and Provider [email protected]

mailto:[email protected]

mailto:[email protected]

Documents

OFFICE OF MEDICAL ASSISTANCE PROGRAMS | September 30, 2011 OFFICE OF ADMINISTRATION State Program Update Panel PHA Annual Conference Laurie Rock Pamela