Medicaid Program Integrity

Presented by:

Christine Martin, RHIA (Thomson Reuters)

Medicaid Program IntegrityIndiana Association for Home and Hospice

Care

August 24, 2011

AGENDA

11 Program Integrity✓

Questions / Contact Information

Patient Protection and Affordable Care Act (PPACA)

Compliance

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Slide 1 of 22

PROGRAM INTEGRITY APPROACH

• Protects public funds

• Encourages compliance

Develop a reasonable and consistent system of oversight of the Medicaid

• Supports awareness and

responsibility

• Maintains accountability

oversight of the Medicaid Program which effectively:

Slide 2 of 22IAHHC– Program Integrity

Managed

CareEducation

Payment

Error Rate

Recoupment

Waivers

Pharmacy

Medicaid

Fraud

PROGRAM INTEGRITY

COMPONENTS

PROGRAM

IError Rate

Measurement

Coverage

& Benefits

Third Party

Liability

Provider

Enrollment

Estate

Recovery

Fraud

Control Unit

Surveillance

Utilization

Review

INTEGRITY

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AGENDA

11 Program Integrity

✓

Questions / Contact Information

Compliance

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✓ Patient Protection and Affordable Care Act (PPACA)

Slide 4 of 22

MOST IMPORTANT MEDICAID INTEGRITY

PROVISIONS OF PPACA

�Mandatory Reporting, Repayment, and Explanation of Overpayments

�Retention of Overpayments Beyond 60 Days is considered a False Claim�Retention of Overpayments Beyond 60 Days is considered a False Claim

�Invokes Penalties and Whistleblower Provisions

�Mandatory Compliance Programs

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MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS

PPACA SECTION 6402

AAReport and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at

“(d) Reporting and Returning of Overpayments – (1) in general, - or a contractor, as appropriate, at

the correct address; and

Notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.”.

Overpayments – (1) in general, -If a person has received an overpayment, the person shall –

B

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OMPP is Developing a Standardized Tool for

Reporting Overpayments

Notify with Reason for Overpayment

REPORT AND RETURN TO CORRECT ADDRESS

In Indiana, overpayments should be returned, reported

and explained to the OMPP SUR Unit at the following

address:

IHCP SUR DepartmentATTN: SUR Audit OverpaymentP.O. Box 636297Cincinnati, OH 45263-6297

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DETERMINING OVERPAYMENTS

• Excluded ordering or

servicing person

• Servicing person

lacked required

license or

Common Reasons for Overpayments:

• May be evident in

the provider’s billing

system

• Payment made by a

primary insurance

• Duplicate payment

for the same service

license or

certification

• No order for services

• Patient is deceased

• Billing system error

• May be identified

through Compliance

Programs and/or

Self-Audits

• Payment for non-

covered, non-

medically necessary

services.

• Services not actually

rendered

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MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS

PPACA SECTION 6402

AAThe date which is 60 days after the date on which the overpayment was identified; or“(2) Deadline for reporting and

returning overpayments. – An

The date any corresponding cost report is due, if applicable.”

returning overpayments. – An overpayment must be reported and returned under paragraph (1) by the later of -

B

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Employee or contractor identifies overpayment in hotline call or e-mail11

22 Patient advises that service was not received

For Example:

WHEN IS AN OVERPAYMENT “IDENTIFIED”?

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RAC advises that dual-eligible Medicare overpayment has been found

Indiana SUR Unit sends a letter notifying that you have billed services

for deceased patient, unlicensed or excluded employee or ordering

physician

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WHAT IF THE IDENTIFICATION OF AN

OVERPAYMENT IS WRONG?

That is why the statute allows providers 60 days from the date of identification

to report the overpayment

Providers need to complete internal review and assessment before reporting

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Not obligated to report any allegations if your investigation shows it is inaccurate

Providers need to complete internal review and assessment before reporting

The risk is on provider who decides not to report, especially if the overpayment

is later confirmed through an external audit by the SUR Unit or the RAC

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AGENDA

11 Program Integrity

Questions / Contact Information

22

33

44

✓

Patient Protection and Affordable Care Act (PPACA)

Compliance

Slide 12 of 22

MEDICARE AND MEDICAID PROGRAM INTEGRITY PROVISIONS

PPACA SECTION 6402

AAKnowing and Knowingly – The terms “knowing” and knowingly” have the meaning given those terms in Section 3729(b) of Title

“(3) Enforcement. – Any overpayment retained by a person after the deadline for reporting and

terms in Section 3729(b) of Title 31, United States Code

Overpayment – The term “overpayment” means any funds that a person receives or retains under title XVII or XIX to which the person, after applicable reconciliation, is not entitled under such title.”

after the deadline for reporting and returning the overpayment under paragraph (2) is an obligation (as defined in Section 3729(b)(3) of Title 31, United States Code) for purposes of Section 3729 of such title (False Claims Act)”

B

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1. Actual Knowledge of the

Information

WHAT IS KNOWING & KNOWINGLY

KnowledgeInformation

2. Deliberate Ignorance of the Truth

or Falsity of the Information

3. Acts in Reckless Disregard of the

Truth or Falsity of the Information

IgnoranceFalsity

Slide 14 of 22IAHHC – Compliance

Payment “received or retained” in violation of Federal Law11

22Payment “received or retained” for services where order for services

induced by kickback

OVERPAYMENT INCLUDES

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induced by kickback

Credit Balance

Payment “received or retained” for services ordered or provided by

excluded person (42 CFR 10001.1901 forbids payment for services

ordered or furnished by excluded persons)

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RAC – RECOVERY AUDIT CONTRACTOR

• Federally mandated via section 6411 of the Affordable Care

Act which amends section 1902(a)(42) of the Social Security

Act

• Final regulations are still pending Indiana has contracted for

RAC Audits with Health Management Systems (HMS)

• HMS is subcontracted with Thomson Reuters as one

component of the overall FADS solution

• RAC contract begins September 2, 2011

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IMPORTANT RAC CONSIDERATIONS -COORDINATION

�CMS mandates that States and their Medicaid RACs must coordinate their recovery audit efforts with other entities to minimize the likelihood of overlapping auditsoverlapping audits

�OMPP will coordinate audits through its arrangement with Thomson Reuters, which includes coordination with the RAC

�Additional coordination includes regular meetings with the Managed Care Entities and the Medicaid Fraud Control Unit

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IMPORTANT RAC CONSIDERATIONS - APPEALS

CMS requires States to have an adequate process for entities to appeal anyadverse decisions made by the Medicaid RACs.

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Appeals must be filed in accordance with IC 4-21.5-3 and 405 IAC 1-1.5-2. Withthe Appeal, a Statement of Issues must be filed which must conform to 405 IAC1-1.5-2. Both the Appeal and the Statement of Issues must be filed within 60days of receipt of notice.

Indiana has existing administrative appeals processes with respect to audits ofMedicaid providers which will also accommodate Medicaid RAC appeals.

2

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AGENDA

11 Program Integrity

22

33

44✓

Patient Protection and Affordable Care Act (PPACA)

Compliance

Questions / Contact Information

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WWW.IN.GOV/FSSA

‘Contact Us’ Slide 20 of 22

SCROLL DOWN…

Include Attn: Program Integrity

Direct to OMPP

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CONTACT INFORMATION

Only formal responses to questions asked through the

www.in.gov/fssa inquiry process will be considered official and valid

by the State. No participant shall rely upon, take any action, or make

any decision based upon any verbal communication with any State

employee or designated contractor including responses in today’s

presentation.

indianamedicaid.comindianamedicaid.com 1-800-457-45151-800-457-4515 www.in.gov/fssawww.in.gov/fssa

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