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Program Integrity: Medicaid Managed Care (1915 b/c Waivers). Patrick O. Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section Program Integrity January 27, 2012. Program Integrity. References: 42 CFR 438 (Managed Care) 42 CFR 434 (Contracts)

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program integrity medicaid managed care 1915 b c waivers

Program Integrity:Medicaid Managed Care(1915 b/c Waivers)

Patrick O. Piggott, MSW, LCSW, DCSW

Chief, Behavioral Health Review Section

Program Integrity

January 27, 2012

program integrity
Program Integrity

References:

42 CFR 438 (Managed Care)

42 CFR 434 (Contracts)

42 CFR 455 and 456 (Program Integrity & Utilization Control)

NC Medicaid State Plan

10A NCAC 22F (Program Integrity)

NC GS 108A – 70.10 thru 70.17 (False Claims)

program integrity1
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 1.4 million and HealthChoice is approximately 130,000 recipients.
  • Over 9,000 Behavioral Health Providers
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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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Program Integrity

“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

program integrity4
Program Integrity

Governor’s Initiatives to address Medicaid fraud and abuse:

  • Signed Senate Bill 695, Medicaid Anti-Kickback law
  • 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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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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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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Program Integrity

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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Program Integrity

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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Program Integrity

Provider Abuse

10A NCAC 22F .0301

Provider 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

program integrity10
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 .0106

All 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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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

Trends in Behavioral Health:

  • 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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Program Integrity

Trends in Behavioral Health:

  • 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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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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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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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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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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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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Program Integrity

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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Program Integrity

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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Program Integrity

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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Program Integrity

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 such other such database the Secretary may prescribe.
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Program Integrity

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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Program Integrity

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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Program Integrity

Respond to an Investigation

  • Refer cases of potential Fraud to DMA Program Integrity. DMA will conduct a preliminary Review and determine if case warrants a full Investigation.
  • 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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Program Integrity

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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Program Integrity

May want to establish a Special Investigation Unit to meet the program integrity requirements.

At a minimum must have administrative and management arrangements or procedures including:

  • Mandatory compliance plan designed to safeguard against fraud and abuse in the Medicaid Managed Care program
  • Written policies and procedures and standards of conduct that articulate the organizations commitment to comply with all federal and state standards
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Program Integrity

Minimum cont.

  • Designate a compliance officer
  • Training & education for the compliance officer and organization employees
  • Lines of communication between compliance officer and the organization employees
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Program Integrity

Minimum cont.

  • Enforcement of standards through well publicized disciplinary guidelines
  • Provisions for internal monitoring and auditing
  • Specifies certain prohibitions aimed at the prevention of fraud and abuse.
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Program Integrity
  • Must establish safeguards against conflicts of interests on the part of State & local officers and employees and agents of the State who have responsibilities related to the MCO Contract
  • Prohibit affiliations with individuals debarred by Federal agencies and other Federal health care programs
    • Individuals who are debarred, suspended, or otherwise excluded from participating in procurement activities and non-procurement activities (director, officers, partner, 5% ownership, employee, consultant, or other arrangement)
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Program Integrity
  • Provisions for prompt responses to detected offenses and the development of corrective action initiatives
  • State must notify the Secretary (DHHS) of Noncompliance
  • Impose sanctions (42 CFR 438.700 – 438.808)
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PROGRAM INTEGRITY

Assessment of Categorical risk level-High

( NC GS 108C/Session Law 2011-399 -3 & 42 CFR 455)

Corporate Compliance Plan

Encourage provider QA & QI Program, Self-Audit, and

Self-reporting

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Program Integrity

Current DMA PI Activities:

  • MCOs will have access to closed provider reviews, investigations, or audits
  • MCO may request from Provider Services provider status related to “Good Standing”
  • MCOs will have access to providers on prepayment review
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Program Integrity

Fraud and Abuse Reporting (Provider):

  • Local Managed Care Organizations
  • 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 online complaint form at: http://www.ncdhhs.gov/dma/fraud/reportfraudform.htm
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Program Integrity

Fraud and Abuse Reporting (Recipient):

  • 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
questions or comments
QUESTIONS or COMMENTS

CONTACT:

Patrick O. Piggott, MSW, LCSW, DCSW

Chief, Behavioral Health Review Section

NC DMA – Program Integrity

Phone: (919) 647-8049

Fax: (919) 647-8054

Email: Patrick.Piggott@dhhs.nc.gov