1 PROGRAM INTEGRITY 101 Program Integrity Kimberly Sullivan, JD Medicaid Program Integrity Director
2 PURPOSE 2 Assure the Programmatic and Fiscal Integrity of the Louisiana Medical Assistance Program (Medicaid). In order for DHH to receive the federal share, Federal regulations mandate that DHH perform Program Integrity functions.
4 Rules of the Program 4 MAPIL La. R.S. 42:437.1, et seq. SURS RULE Louisiana Register Vol. 29, No.04, 04/20/2003 Federal Laws and Regulations (CFR) Program Regulations (La. Administrative Code) Provider Manuals/ Standards for Payments Letters from the Medicaid Director Training Manuals Provider Updates RA Messages
5 Provider Enrollment 5 You must have a separate Medicaid Provider Number for each Provider Type Each Provider Type has a separate Provider Enrollment Packet and Disclosure of Ownership registration Each Provider Type has specific conditions of Enrollment All Provider Types have general conditions of Enrollment
6 General Conditions Of Enrollment 6 Your Enrollment in Medicaid is a contractual arrangement. By entering into that contract you have agreed to certain conditions. The general conditions are contained in the PE- 50 Addendum Provider Agreement.
7 Provider Name: PE-50 ADDENDUM PROVIDER AGREEMENT I, the undersigned, certify and agree to the following: Enrollment in Louisiana Medicaid 1. I have read the contents of this Louisiana Medical Assistance Program Enrollment Packet and the information supplied herein is true, correct and complete; 2. I understand that it is my responsibility to ensure that all information is kept up to date on the Louisiana Medicaid Provider File; 3. I understand that failure to maintain current information may result in payments being delayed or closure of my Medicaid provider number; 4. I understand that if my number is closed due to inaccurate information, I will have to complete a new enrollment packet in its entirety to reactivate my provider number; 5. I attest that I am a U.S. citizen or that I have legal status and work privilege in the U.S. 6. I understand that it is my responsibility to ensure that all my employees and/or authorized representatives are U.S. citizens or have legal status and work privilege in the U.S. 7. I understand that it is my responsibility to ensure that neither I, nor any owner(s), manager(s), employee(s), agent(s) or affiliate(s) are not now or have ever been: denied enrollment; suspended, or excluded from Medicare, Medicaid or other Health Care Programs in any state; employed by a corporation, business, or professional association that is now or has ever been suspended or excluded from Medicare, Medicaid or other Health Care Programs in any state; convicted of any crimes. I will report any of the above conditions to Program Integrity at the Department of Health and Hospitals prior to enrolling in Louisiana Medicaid or upon discovery once enrolled. 8. I understand that as part of the Louisiana Medicaid enrollment/re-enrollment process, the Social Security Numbers of any owner(s), manager(s), and board of directors, etc., must be provided. I understand that failure to provide the Social Security Numbers will result in the rejection of my enrollment or re-enrollment request. Providing Services to Louisiana Medicaid Recipients 9. I agree to conduct my activities/actions in accordance with the Medical Assistance Program Integrity Law (MAPIL Louisiana R.S. Title 46, Chapter 3, Part VI-A) as required to protect the fiscal and programmatic integrity of the medical assistance programs; 10. I understand that services and/or supplies provided by me must be medically necessary and medically appropriate for each individual patient based on needs presented on the date the service is provided and/or delivered; 11. I agree to charge no more for services to eligible recipients than is charged on the average for similar services to others; 12. I understand that as the provider I am held responsible for any and all claims submitted under any Louisiana Medicaid provider number issued to me; 13. I agree to maintain all records necessary for full disclosure of services provided to individuals under the program and to furnish information regarding those records as well as payments claimed/received for providing such services that the State Agency, the Department of Health and Hospitals (DHH) Secretary, the Louisiana Attorney General, or the Medicaid Fraud Control Unit may request for five years from the date of service; 14. I agree to report and refund any discovered overpayments; 15. I agree to participate as a provider of medical services and shall bill Medicaid for all covered services performed on behalf of an eligible individual who has been accepted by me as a Medicaid patient. I agree to accept a client s Medicaid card as payment in full for covered services rendered. I agree to bill Medicaid for all services covered by Medicaid that will be provided to eligible Medicaid clients; 16. I agree to accept Medicaid payment for covered services as payment in full and not seek additional payment from any recipient for any unpaid portion of a bill, with the exception of state-funded spend-down Medically Needy recipients as indicated by the agency s form 110-MNP or any recipient co-payments as established by the DHH; 17. I agree to adhere to the published regulations of the DHH Secretary and the Bureau of Health Services Financing, including, but not limited to, those rules regarding recoupment and disclosure requirements as specified in 42 CFR 455, Subpart B; 18. I agree to adhere to the federal Health Insurance Portability and Accountability Act (HIPAA) and all applicable HIPAA regulations issued by the federal Department of Health and Human Services, including, but not limited to, the requirements and obligations imposed by those regulations regarding the conduct of electronic health care transactions and the protection of the privacy and security of individual health information and any additional regulatory requirements imposed under HIPAA; -- continued -- 7
8 19. I understand the Louisiana Medicaid Program must comply with Department of Health and Human Services (DHHS) regulations promulgated under Title VI of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973, as amended; and the American Disabilities Act of 1990 which require that: No person in the United States shall be excluded from participation in, denied the benefits of, or subjected to discrimination on the basis of age, color, handicap, national origin, race or sex under any program or activity receiving Federal financial assistance. Under these requirements, Louisiana s Department of Health and Hospitals, Bureau of Health Services Financing cannot pay for medical care or services unless such care and services are provided without discrimination based on age, color, handicap, national origin, race or sex. Written complaints of noncompliance should be directed to Secretary, Department of Health and Hospitals, PO Box 91030, Baton Rouge, LA or DHHS Secretary, Washington, DC or both. 20. The Deficit Reduction Act of 2005, Section 6032 Implementation. As a condition of payment for goods, services and supplies provided to recipients of the Medicaid Program, providers and entities must comply with the False Claims Act employee training and policy requiements in 1902(a)(68) of the Social Security Act, set forth in that subsection and as the Secretary of the US Department of Health and Human Services may specify. As an enrolled provider/entity, it is your obligation to inform all of your employees and affiliates of the provisions of the Federal False Claims Act, and any Louisiana laws and/or rules pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws and/or rules. When monitored or audited, you will be required to show evidence of compliance with this requirement. Medicaid Direct Deposit (EFT) Authorization Agreement 21. I have reviewed the Medicaid Direct Deposit (EFT) Authorization Agreement and the Medicaid Provider Requirements and Conditions as listed below and agree to this agreement: I understand that payment and satisfaction of any claims will be from Federal and State Funds; and any false claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable Federal and State laws. I understand that DHH may revoke this authorization at any time. I hereby authorize the Louisiana Department of Health and Hospitals to present credit entries into the account and the depository name referenced on the EFT Authorization Agreement form. These credits will pertain only to direct deposit transfer payments that the payee has rendered for Medicaid services. I certify that if a Board of Directors approval was necessary to enter into this agreement, that approval has been obtained and the signature below is authorized by the stated Board of Directors to enter into or change this agreement. I agree to notify the Provider Enrollment Unit if changing financial institutions or accounts. I further understand that the maintenance of account information on the Louisiana Medicaid files is the provider s responsibility and failure to notify the Provider Enrollment Unit as noted may result in Medicaid payments being electronically transmitted to incorrect accounts. I understand that such changes may not be able to be accommodated if less than 15 business days notice is given. Certification of Claims (Paper & Electronic) 22. I certify that all claims provided to Louisiana Medicaid recipients will be necessary, medically needed and will be rendered by me or under my personal supervision; 23. I understand that all claims submitted to Louisiana Medicaid will be paid and satisfied from federal and state funds, and that any falsification or concealment of a material fact, may be prosecuted under Federal and State laws; 24. I attest that all claims submitted under the conditions of this Agreement are certified to be true, accurate, and complete. Print Name of the Authorized Representative Title / Position Signature of the Authorized Representative Date of Signature
9 Questions and Answers 9 Changes You are required to report changes to Provider Enrollment in a timely manner Your request must be in writing and signed by the individual provider or the entity s authorized agent. Change requests are to be mailed to Provider Enrollment with original signature(s).
10 Questions and Answers 10 Changes All changes must be reported to Provider Enrollment. Making changes on the claims forms will not change your information on the Provider file. If you have a license, you must also report changes to the Licensing agency as well as Provider Enrollment.
11 Questions and Answers 11 Direct Deposit Very Important If you change your Direct Deposit do not close the old bank account until you receive a paper check or payment in the new account. If you change Direct Deposit it will take about three weeks before it is deposited into your new account. You will receive payment via paper check for about 2 weeks following the request to change Direct Deposit.
12 Questions and Answers 12 Changes It takes about three weeks to process a change. There are about 30,000 providers enrolled in Medicaid Molina Provider Enrollment receives about 2,500 written change requests per month.
13 Questions and Answers 13 Closure Provider Numbers are routinely closed for various reasons Returned mail 18 months of no claims activity (auto-closure) Provider sanctioned - Exclusions or Licensing issues
14 Questions and Answers 14 Contacting Provider Enrollment Do not contact Provider Enrollment for the following: Billing inquires Requests for Billing forms Request for Manuals. Contact Provider Relations at
15 Questions and Answers 15 Contacting Provider Enrollment Phone Mail Molina Provider Enrollment, PO Box 80159, Baton Rouge, LA Internet
16 Administrative Sanctions 16 Health Care Fraud (a.k.a. Mandatory Exclusion): Federal Regulations and the SURS Rule prohibit individuals and/or entities that have been excluded from a government funded health program and/or convicted of health care fraud from participating in Medicaid or any other federally funded health care program Other Crimes and Activities (a.k.a. Permissive Exclusions): The SURS Rule contains other crimes and activities for which an individual and/or entity may be excluded from Medicaid
17 Administrative Sanctions 17 State Law now provides that an excluded individual is subject to Felony conviction if that individual continues to participate in the Medical Assistance program.
18 Administrative Sanctions 18 Practice Restrictions Under the SURS Rule, if an individual and/or entity has restrictions placed on them by other governing boards, we will also place those restrictions on the individual and/or entity.
19 Sanctioned Providers and Individuals 19 Under the SURS Rule, providers have an obligation to make sure that anyone who works for you has not been excluded, convicted and/or restricted. Providers should perform background checks on all owners, managers and employees and contact the appropriate licensing boards prior to hire and monthly thereafter. All providers should check the following websites at the time of hire and monthly thereafter, to ensure that all owners, managers and employees have not be excluded from participation in any federal healthcare program: OIG website: EPLS website: Failure to do so will result in sanctions, including, but not limited to, recovery, fines and /or exclusion from Medicaid.
20 Detection 20 Complaints Received via telephone, fax, postal mail or from website: Received from private citizens, other sections of DHH and other agencies Triaged by Complaint Team Logged, investigated and tracked to completion
21 Investigations 21 Obtaining Records: Letter Notification You copy the records & mail them to DHH Onsite We arrive at your facility and copy the records (can be announces or unannounced) NOTE: We have an absolute right to copy and review Medicaid recipient records. We are exempt from HIPAA privacy regulations We DO NOT pay for copies
22 Investigations 22 Investigation Actions: No action Educational Letter Notice of Sanction Letter
23 Enforcement 23 Program Integrity Cases Are Opened When: Complaints are received Unusual Billing Patterns are Found During Data Mining
24 Enforcement 24 The Review Process All relevant laws, regulations, program manuals, written policies, provider updates, RA messages & Medicaid Director Letters are reviewed to determine what is required The billing records are compared to the records obtained from the provider
25 Enforcement 25 Primary Violations Found During Program Integrity Reviews: Undocumented Services No documentation to support the service billed if it is not documented, then it was not performed Altered Documentation Documentation is not corrected using the legal method Poor Record Keeping Records are not in compliance with the Medicaid Program s requirements Medically Unnecessary Services Documentation in your record does not support the medical necessity of the service billed Up-coding Documentation in your record does not support the level of service billed Unbundling of Services The service was billed individually; however, should have been billed in a group
26 Questions & Answer 26 What will happen if I do not cooperate with Program Integrity? We will hold your payments until you comply If I ignore you will you go away? No
27 Questions & Answers 27 Am I responsible for rules that I do not know about? You are responsible for all written laws, regulations and policies that apply to your provider type. Ignorance of the rules is not a defense in our administrative process.
28 Questions & Answers 28 Will you hold me responsible for the actions of my employees? Yes. If you are aware of an employee problem, then inform Program Integrity IMMEDIATELY
29 Questions & Answers 29 How can I reduce my risk and liability? Know and follow the rules of the game Make sure your employees know and follow the rules of the game Follow the rules of the program. Audit yourself to make sure you are following the rules of the game Perform background checks on employees
PROGRAM INTEGRITY 101 Program Integrity Kimberly Sullivan, JD DHH Deputy General Counsel PURPOSE 2 Assure the Programmatic and Fiscal Integrity of the Louisiana Medical Assistance Program (Medicaid). In
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