Detecting and Decreasing Waste, Abuse & Fraud

1. Office of Inspector General 2013 Texas Oral Health Coalition, Oral Health Summit November 22, 2013 Detecting and DecreasingWaste, Abuse & Fraud

2. Governor EXECUTIVE COMMISSIONER Inspector General Health & Human Services Commission COMMISSIONER COMMISSIONER COMMISSIONER COMMISSIONER DADS DSHS DFPS DARS Aging & Disability Services State Health Services Family & Protective Services Assistive & Rehab Services Office of Inspector General

3. Areas of Responsibility Burdens of Proof: • Office of Inspector General (OIG) Administrative – preponderance of evidence • Office of Attorney General (OAG) Civil & Criminal – culpable mental state • Each recognize various levels of involvement: Knowingly Intentionally Recklessly Willfully Negligence

4. Waste, Abuse & Fraud The Causes

5. What is Waste, Abuse, & Fraud? Waste Practices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items, or services. Abuse Practices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary program cost or in reimbursement for services that are not medically necessary, do not meet professionally recognized standards for health care, or do not meet standards required by contract, statute, regulation, previously sent interpretations of any of the items listed, or authorized governmental explanations of any of the foregoing. Fraud Any act that constitutes fraud under applicable federal or state law, including any 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. Fraud may include any acts prohibited by the Texas Human Resources Code, Chapter 36 or Texas Penal Code, Chapter 35A.

6. ‘Red Flags’ of Fraud • Personal Pressures • Finances. • Personal Feelings. • Personal Characteristics • Rationalization of behavior. • Lack of stability. • Organizational Opportunities • Accounting practices. • Firm characteristics. • Organizational Pressures • Business decisions. • Legal difficulties. • Institute of Internal Auditors – Ethics Panel:

7. Who Commits Waste, Abuse & Fraud? Anybody can! • State employees. • Managed Care Organizations. • Contractors and subcontractors. • Providers and their staffs. • Recipients and beneficiaries.

8. Waste, Abuse & Fraud The Problem

9. Provider Fraud • Main Concerns: • Inflating bills. • Double-billing. • Up-coding / unbundling. • Billing for unnecessary services. • Billing for services never rendered. • Reporting phantom visits. • Inappropriate cost shifting. • Billing for service previously provided.

10. Durable Medical Equipment Fraud Main Concerns: • Drop-shipping supplies. • Defective wheelchairs and other equipment. • Fraudulent billing. • Not checking with clients. • Falsification of signatures. • Solicitation. • Documentation.

11. Medical Transportation Fraud • Main Concerns: • Emergency vs. Non-Emergency. • Misrepresenting the client’s condition. • Billing for en-route supplies when none used. • Indicating ‘severely disabled’ when not. • Cancelled requests or no-shows. • No Medicaid-covered services received. • False claims for transport outside county. • False authorization.

12. Healthcare Organization Fraud • Main Concerns: • Procurement of managed care contracts. • Marketing, enrollment, and de-enrollment. • Underutilization. • Claims submission and billing procedures. • Antitrust violations. • Fraud or abuse in the FFS component. • Embezzlement and theft.

13. Beneficiary Fraud • Main Concerns: • Eligibility: • Income – Resources. • Family composition / Residency. • Misuse of Benefits: • Recipient card sharing. • Misuse of medical services. • Misuse of prescription medications. • Altering of prescriptions. • Trafficking in Lone Star Cards. • Failure to report private insurance.

14. Waste, Abuse, & Fraud The Process

15. The Usual Process • Allegation / Report • Investigation / Finding • Hearing / Trial • Civil Penalties / Exclusion

16. Investigation Process • Medicaid Provider Integrity • Each complaint is reviewed by an • intake investigator. The results can • be one or more of the following: • - case closure • - provider education • - referral to a licensure board • - payment hold • - referral to the Attorney General • - full scale investigation

17. Potential Remedies • Sanctions • Recoupment of Overpayments • Civil Monetary Penalties for False Claims • Exclusion • Payment Hold • Contract Cancellation • Restricted Reimbursement • Recoupment of Other Funds • Administrative Actions • Pre-Payment Holds • Educational Sessions • Prior Authorization • Corrective Action Meetings • Surety Bonds

18. Waste, Abuse & Fraud The Solution

19. Eliminate WAF: Plan & Control • Develop a Prevention Plan: • Designate a key Compliance Officer or Compliance Team. - Outline specific roles / responsibilities. - Specify the scope of authority. - Define relationship with other areas (i.e. OIG, TMHP, etc.). - Identify and measure risks. - Analyze all aspects of your program. - What are your ‘Red Flags’? - What factors are critical? - Identify what is in your direct control, and what isn’t.

20. Eliminate WAF: Educate & Implement • Develop Learning Functions: • Train in awareness and prevention. - Intake staff in telephone skills, probing questions, program specifics. - MTP clients, Transportation provider, Medical providers in responsibilities. - Implement and monitor controls. - Create a ‘triage’ process to assess. - Have regular discussions on potential WAF issues and responses. - Identify how you know you are succeeding.

21. Eliminate WAF: Document & Build • Develop Integrity Functions: - Document everything. - Build good data collection & record keeping into your processes. • Encourage continuous improvement. - Keep current and active in state and federal trends, initiative, and statutes that impact your program. - Ask, “What if . . .” to create ideas, build innovation, and improve service. - Don’t get stuck in, “We’ve always done it that way.”

22. Waste, Abuse & Fraud Responsibility to Report

23. Why Report Waste, Abuse & Fraud? • It cheats everyone. All these activities cost taxpayers and good providers, siphon money from patient care, and increase state, federal, and managed care oversight and investigative costs. • It hurts Medicaid clients. These activities can result in individuals not receiving care that is medically necessary, or receiving unnecessary or even harmful care. • It’s illegal. Fraud or abuse can result in civil or criminal liability. Not only is the person who knowingly falsifies records or claims responsible, so is the person telling them to do so and anyone who knew or should reasonably have known what was happening.

24. Excessive and below standard of care dental services

25. Falsified Documentation Lower Right Lower Left

26. Falsified Documentation Panoramic x-ray Intra-oral of lower arch

27. Inaccurate Documentation 2009 Bitewing x-rays 2010 Bitewing x-rays

28. Questions/Contact Information Linda M. Altenhoff, DDS Chief Dental Officer 512.491.1106 Linda.Altenhoff@hhsc.state.tx.us

29. Contact • OIG Website https://oig.hhsc.state.tx.us/OIG_home.aspx • OIG Hotline 1-800-436-6184 • OIG Training Coordinator Todd Shaw 512-491-2059 todd.shaw@hhsc.state.tx.us