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1
VBH-PA Provider
Self-Audit Protocol
Jennifer Putt, CFE
Manager of Program Integrity
August 12, 2016
VBH-PA Provider Self-Audit Protocol
Topics for Today’s Presentation
2
Background and Requirements for Provider Self-Audits
Examples of Inappropriate Payments Suitable for Provider Self-Audits
Types of Provider Self-Audits
VBH-PA Provider Self-Audit Protocol
VBH-PA Provider Self-Audit Protocol
Background and
Requirements
for Provider
Self-Audits
3VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
4
Federal Requirements:
OIG Department of Health and Human Services: Self-Disclosure Protocol:
Provider Self-Disclosure
HHS Contractors and Self-Disclosures
HHS Grantee Self-Disclosure
Self-disclosure can reduce the civil penalties and corrective actions that can be imposed for overpayments
https://oig.hhs.gov/compliance/self-disclosure-info/index.asp
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
5
OIG Provider Self-Disclosure
OIG self-audit protocol introduced in 1998
Process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud
OIG emphasizes that the health care industry has a legal and ethical duty to report overpayment and potential fraud, which includes the following obligations:
Taking measures to detect and prevent fraudulent and abusive activities
Implementing specific procedures and mechanisms to investigate fraud
Resolving and correcting to prevent future instances of potential fraud
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
6
OIG Provider Self-Disclosure
Benefits of “good faith” disclosures and cooperation with the OIG:
Provides evidence of a robust compliance program
Allows for integrity agreements instead of exclusion
Allows for lower multiplier and single damages
Prevents suspension of future payments
Reduces OIG investigations
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
7
Pennsylvania Requirements
Medical Assistance Bulletin 99-02-13, The Bureau of Program Integrity and the Medical Assistance Provider Self-Audit Protocol:
Requires all providers to conduct self-audits and return overpayments in accordance with the protocol
Requires all Managed Care Organizations to have provider self-audit protocols and processes for HealthChoices
http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_004259.pdf
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
8
Medical Assistance Bulletin 99-02-13
BPI suggests that providers consider the following recommendations to ensure compliance with MA regulations and avoid possible sanctions and penalties:
Providers should be aware of billing requirements and compensable services under the MA Program.
Providers, to the extent practicable, should adopt and implement compliance plans to ensure that they remain in compliance with MA regulations.
As part of a compliance plan, providers should periodically conduct self-audits to ensure compliance with MA regulations.
To the extent that overpayments are identified, providers should utilize the MA Provider Self-Audit Protocol to facilitate the return of overpayments.
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
9
Medical Assistance Bulletin 99-02-13
BPI can take the following actions for providers that do not identify and return overpayments:
Educational and training letters;
Recover improperly paid funds;
Terminate a provider’s provider agreement and preclude a provider’s direct and indirect participation in the MA Program;
Refer the case to the Attorney General’s MFCU or other appropriate criminal law enforcement agency;
Refer a case to an appropriate civil agency
Seek a civil monetary penalty amounting to twice the overpaid amount plus interest; or
Recommend internal policy changes to improve and/or clarify program standards.
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
10
Medical Assistance Bulletin 99-02-13
BPI states that providers will receive the following benefits from self-disclosure:
DHS will not seek double (or triple) damages, but will accept repayment without penalty if self-audits are voluntary and identified by provider prior to an oversight audit
DHS can provide assistance and training during the self-audit processes
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
11
Medical Assistance Bulletin 99-02-13
BPI states that MCOs should have self-audit protocols for providers:
MCOs are required to have a provider self-audit protocol
MCOs are required to educate providers on self-audits
MCOs should work collaboratively with BPI and DHS on provider self-audits
VBH-PA Provider Self-Audit Protocol
Background and Requirements for Provider Self-Audits
12
Pennsylvania Requirements
PA Department of Human Services (DHS) Bureau of Program Integrity (BPI) Information on provider self-audit protocols:
Provides options for conducting self-audits directly with DHS and BPI
VBH-PA has a similar provider self-audit protocol for HealthChoices services and members
http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/medicalassistanceproviderselfauditprotocol/
VBH-PA Provider Self-Audit Protocol
13
Examples of
Inappropriate
Payments Suitable
for Provider Self-
Audits
VBH-PA Provider Self-Audit Protocol
Fraud, Waste, and Abuse
14
Fraud must be reported and will result in overpayments that providers need to return
Fraud can result in civil and criminal penalties
Fraud may be identified through self-audits
Fraud: Any intentional deception or misrepresentation made by an entity or person in a capitated MCO, Primary Care Case Management (PCCM), or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting
VBH-PA Provider Self-Audit Protocol
Fraud, Waste, and Abuse
15
Providers must return overpayments from abuse and waste within 60 days or the overpayments held can be considered fraud
Abuse: Any practices in a capitated MCO, Primary Care Case Management (PCCM) program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting
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
VBH-PA Provider Self-Audit Protocol
Fraud, Waste, and Abuse
16
Fraud, waste, and abuse that can result in provider overpayments:
Any services that are out of compliance with PA or Federal Code
Any services that are out of compliance with PA Medical Assistance Payment Regulations
Any services that do not meet the VBH-PA Provider Manual requirements or minimum documentation standards
Any services that are not within the scope of practice standards or service descriptions
VBH-PA Provider Self-Audit Protocol
Examples of Inappropriate Payments Suitable for Provider Self-Audits
17
A psychiatric inpatient hospital provider bills and received payment for primary Drug and Alcohol services not payable to a psychiatric hospital or hospital psychiatric unit
A provider bills MA with an incorrect prescriber’s or practitioner’s license number
A mental health outpatient clinic determines that psychotherapy groups had more than 10 participants, when payment regulations require psychotherapy groups to be for 2 to 10 members for at least a continuous 60 minutes
VBH-PA Provider Self-Audit Protocol
Examples of Inappropriate Payments Suitable for Provider Self-Audits
18
A family based mental health services or behavioral rehabilitation provider discovers that clinicians are billing for travel or no shows
A psychiatric partial hospitalization program bills for time spent transporting the client to and/or from the partial program or for time spent in activities away from the licensed site
VBH-PA Provider Self-Audit Protocol
Examples of Inappropriate Payments Suitable for Provider Self-Audits
19
Two or more physicians involved in rendering an inpatient service bills different procedure codes for the same service
A methadone maintenance provider bills for services provided prior to the clinic supervisory physician’s examination/evaluation and/or treatment plan
A psychiatric outpatient clinic bills for a medication administration visit when no medication was administered
VBH-PA Provider Self-Audit Protocol
Types of Provider Self-Audits
20VBH-PA Provider Self-Audit Protocol
Types of Provider Self-Audits
21
Self-Audit and Adjustments for Errors without Patterns
Individual Claims Adjustments:
Documentation errors and overpayments that are limited to a specific occurrence through standard monitoring and auditing
Errors have no patterns and are not repetitive
Error rate is below a pre-determined threshold
Example: During a quarterly review of 25 member records, a provider discovers the following: 23 member records have no errors,1 member record has incomplete treatment plan review, and 1 member record is missing a progress note
Through the self-audit process, the provider will request specific claims adjustments for the claims associated with the incomplete treatment plan and the claim for the missing progress note
VBH-PA Provider Self-Audit Protocol
Types of Provider Self-Audits
22
Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences
100% Review of Claims:
Documentation errors and overpayments are repetitive and consistent through the review
Error rate is above a pre-determined threshold
Case-by-case review of claims is administratively feasible and cost-effective
Example: During a quarterly review of 25 member records, a provider discovers the following: 20 member records have no findings and 5 member records has missing encounter forms for various dates of service
The provider determines the missing encounter forms are from a new clinician that has only been providing service for 6 months
The provider decides to review 100% of the new clinician’s claims to determine the error rate of missing encounter forms to calculate the correct overpayment and implement corrective actions
VBH-PA Provider Self-Audit Protocol
Types of Provider Self-Audits
23
Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences
Provider-Developed Self-Audit Work Plan:
Documentation errors and overpayments are repetitive and consistent through the review
Case-by-case review of claims is NOT administratively feasible and cost-effective
The provider must project the actual error rate and overpayments
Example: During an on-site CMS review of 100 claims, CMS discovers the following: 60 claims have no findings and 40 claims were for group services that had more than 10 participants
The provider determines a case-by-case review of claims is NOT administratively feasible and cost-effective because there are 10,000 claims that require member record reviews
The provider decides to submit a plan to use CMS error rate and extrapolation to calculate overpayments and implement corrective actions
VBH-PA Provider Self-Audit Protocol
24
VBH-PA
Provider
Self-Audit
Protocol
VBH-PA Provider Self-Audit Protocol
VBH-PA Provider Self-Audit Protocol
25
The VBH-PA Provider Self-Audit Protocol provides detailed instructions and is available at the following:
http://www.vbh-pa.com/fraud/pdfs/Provider-Self-Audit-Protocol.pdf
VBH-PA allows providers to select the methodology of self-audit based on the types of self-audits:
Self-Audit and Adjustments for Errors without Patterns
Individual Claims Adjustments
Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences
100% Review of Claims
Provider-Developed Self-Audit Work Plan
VBH-PA Provider Self-Audit Protocol
VBH-PA Provider Self-Audit Protocol
26
The VBH-PA Provider Self-Audit Protocol provides instructions on how to use each of the forms available online:
http://www.vbh-pa.com/fraud_abuse.htm
Attachment #1: VBH-PA Claims Spreadsheet
Attachment #2: VBH-PA Provider Self-Audit Referral Form
Attachment #3: VBH-PA Provider Audit Response
Attachment #4: VBH-PA Provider Self-Audit Work Plan Form
VBH-PA Provider Self-Audit Protocol
VBH-PA Provider Self-Audit Protocol
27
Additional Tips for the VBH-PA Provider Self-Audit Protocol:
All information related to self-audits should be sent to the following email: [email protected]
If you do not have encrypted email, you must contact the above email before sending member information
A VBH-PA Program Integrity Auditor will be assigned to each provider self-audit and will assist the provider through the steps of the protocol
Please visit the VBH-PA Program Integrity Contact Information on Fraud and Abuse webpage
VBH-PA Provider Self-Audit Protocol
28
Review of VBH-PA
Provider Self-
Audit Protocol
Giving Value Back to the Provider 2016
http://www.vbh-pa.com/fraud_abuse.htm
Review Documents on VBH-PA Webpage
29VBH-PA Provider Self-Audit Protocol
30
Questions?
VBH-PA Provider Self-Audit Protocol
31
Thank you
VBH-PA Provider Self-Audit Protocol