Transcript Efforts of Program Integrity in NC by

Program Integrity
Fraud, Waste & Abuse
Sandhills Center LME
NC Medicaid
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Based on its budget, Medicaid is one of the
largest health care companies in NC.
Serves 1.5 million people annual; expected
to increase by 500,000 – 700,000 by 2014.
Must have a system in place to prevent
improper payments and reduce fraud &
abuse.
Definitions
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Fraud: Deception or misrepresentation
made by a health care provider with the
knowledge that the deception could
result in some unauthorized benefit to
him or herself or other person. Includes
any act that constitutes fraud under 42
CFR 455, the federal laws governing
Program Integrity for Medicaid.
Definitions
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Waste: The over utilization of services, or
other practices that result in unnecessary
costs generally not considered caused by
criminal negligent actions but rather the
misuse of resources.
Definitions
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Abuse: Provider practices that are
inconsistent with sound fiscal, business
or clinical practices and result in an
unnecessary cost to the Medicaid
program, or in reimbursement for
services that are not medically necessary
or fail to meet recognized standards for
health care or clinical policy.
Fraud & Abuse Laws
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False Claims Act: Knowingly submits,
or causes another person or entity to
submit, false claims for payment of
government funds
Filing false claims may result in fines
of up to 3 times the programs’ loss
plus $11,000 per claim filed.
Fraud & Abuse Laws
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Anti-Kickback Statute: A criminal law
that prohibits the knowing and willful
payment of remuneration to induce or
reward patient referrals or the
generation of any business involving
any item or service payable by any
federal healthcare program.
Fraud & Abuse Laws
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Self-Referral Law, commonly known as
the Stark Law: Pertains to physician
referrals under Medicare and Medicaid.
This law prohibits physicians from
referring patients to receive services
from entities with which the physician
or an immediate family member has a
financial relationship.
Fraud & Abuse Laws
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False Claims Act Whistleblower
Employee Protection Act: This law
was enacted to protect employees
from being discharged, demoted,
suspended, threatened, harassed or
discriminated against because the
employee testifies or assists with an
investigation of the employer.
Fraud & Abuse Laws
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Exclusion Statute: This law explains
that the Office of Inspector General
(OIG) is legally required to exclude
individuals/entities from participation
in all federal health care programs if
convicted of certain offenses.
Fraud & Abuse Laws
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Civil Monetary Penalties Law: This law
allows the OIG to seek civil monetary
penalties and assessments based on
the type of violation. Penalties range
from $10,000 to $50,000 per violation.
Mission of Program
Integrity
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Ensure compliance, efficiency and
accountability with the NC Medicaid Program
by detecting and preventing fraud, waste and
program abuse; and
Detect improper payments of Medicaid dollars
through cost avoidance activities, recoupments
and ongoing education of providers and
members.
Program Integrity
Objective
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To eliminate fraud, waste and abuse
within the Sandhills Center Provider
Network by implementing a proactive
data driven process to identify and
address potential discrepancies and
red flags.
Interventions & Strategies
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Provide education, training and/or guidance
for both Medicaid members and providers of
Medicaid services;
Support efforts of providers who identify and
resolve issues themselves;
Hold provider agencies accountable when no
systems are in place to guard against fraud,
waste and abuse;
Interventions & Strategies
Cont’d
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Support use of tools such as payment
suspension, post payment reviews, audits,
and sanctions; and
Encourage and maintain open lines of
communication between the program and
the public on the effectiveness of PI
activities, which include recoupment and
cost reduction.
Interventions & Strategies
Cont’d
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Monitor providers regularly to determine
compliance
Take corrective action if failure to comply
Implement mechanisms to detect under and
over utilization of services
Implement mechanisms to assess quality
and appropriateness of care
Ensure providers are credentialed.
Expected Benefits
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Enhance Provider Education;
The shift to a more proactive/preventive model;
Improved guidance on reimbursement policies &
provider enrollment requirements; and
Improved detection
Examples of Medicaid Fraud
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Billing for “phantom patients” who
really did not receive services;
Billing for medical services or goods
that were not actually provided;
Billing for more services than could be
provided in 24 hours in a day;
Paying a kickback in exchange for a
referral for services or goods;
Examples of Medicaid Fraud
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Concealing ownership in a related
company;
Using false credentials for staff;
Providing services by untrained staff;
Billing for unnecessary tests; and/or
Overcharging for health care services
or goods that were provided.
Session Law 2011-399
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Also known as Senate Bill 496
Modified the General Statutes by adding a new
chapter, 108C titled “Medicaid and Health Choice
Provider Requirements.”
Applies to providers enrolled in Medicaid or
Health Choice
Includes the following provisions:
– Provider Screening which assigns a risk level
to providers of limited, moderate or high.
Session Law 2011-399
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Criminal History Record Checks
Payment Suspension and Audits (includes
voluntary self-audits)
Prepayment Claims Review
Threshold recovery amount ($150)
Provider Enrollment Criteria
Provider Cooperation with Investigations &
Audits
Appeals by Medicaid Providers & Applicants
Provider Self-Audit Process
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Process has been in place since 1999;
now being expanded to incorporate new
activities based on Session Law 2011399.
In accordance with NC Session Law
2011-399, “low” or “moderate” risk
providers do have the opportunity to
conduct self-audits as a method of
contesting the outcome of a PI audit.
Suspension of Payments
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In accordance with 42 CFR 455.23,
payments may be suspended if/when
a credible allegation of fraud is
received and investigation pending.
Note: DMA is the only authorized
entity that can suspend payment
based on a credible allegation of
Fraud/Waste/Abuse.
DMA Contract Requirements –
Fraud and Abuse
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Policy and Procedure Driven:
– Procedure to verify services paid by
Medicaid were actually delivered;
– P&P that clearly articulate SHC’s
commitment to comply with all standards;
– Designation of a compliance officer and
committee accountable to management;
– Effective Training & Education;
– Effective lines of communication between
the compliance officer and staff;
DMA Contract Requirements –
Fraud and Abuse Cont’d
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Enforcement of Standards through wellpublicized disciplinary guidelines;
Internal monitoring and auditing;
Prompt response to detected offenses
including corrective action initiatives;
Development and maintenance of
Compliance Plan; and
Notification to DMA-PI of all credible
allegations of fraud or abuse.
Sandhills Center PI Efforts
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Implementation of Regulatory Compliance
Plan;
Designation of a Regulatory Compliance
Officer;
Establishment of a Regulatory Compliance
Committee
Education and Training
Monitoring Activities – internal and external
Sandhills Center PI
Efforts
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Development of Program Integrity
Team whose responsibilities include
but are not limited to:
– Data mining and analysis
– Determining confidence levels for data
– Conducting investigations for referrals of
F/W/A
– Referral of cases of suspected F/W/A to
appropriate oversight agencies
Identification of Potential
F/W/A
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Sources include:
– Data Analysis Reports
– Post payment Claims Reviews
– Requests from SHC Internal Departments
– Calls or Complaints
Activities to Detect & Prevent
Fraud and Abuse
Examples include:
– Review of OIG database and National
Practitioner Data Bank (NPDB) for exclusions;
– Falsification of Provider Qualifications;
– Authorization requests for non-covered services;
– Extending the length of treatment or delays in
discharging;
– Duplicate entry of claims for the same member
by the same provider
– Pattern of large volume of complaints against a
provider
References
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42 CFR 438 (Managed Care)
42 CFR 434 (Contracts)
42 CFR 455 & 456 (PI & Utilization Control)
False Claims Act (31 USC §3729-3733)
Anti-Kickback Statute (42 USC §1320a-7b(b)
Self-Referral Law (42 USC §1395nn)
Exclusion Statute (42 USC §1320a-7)
Civil Monetary Penalties Law (42 USC
§1320a-7a)