Provider Training Series The Search for Compliance Annual Mandatory Training for all Providers

Transcription

1 Provider Training Series The Search for Compliance Annual Mandatory Training for all Providers Melissa Hooks, Director of Program Integrity

2 Annual Training for All Providers Compliance with Medicaid Detection and Prevention of Fraud, Waste, and Abuse

3 Purpose of the Annual Training All participants and down-stream entities of Medicare and Medicaid are required to have annual trainings. 1. Compliance: Fraud, Waste, and Abuse 2. Overview of Regulations 3. Federal Compliance Program Requirements 4. Provider Responsibilities 5. Medicaid and BH-MCO Prevention and Detection

4 Compliance: Fraud, Waste, and Abuse (FWA)

5 Fraud, Waste, and Abuse 1. Definitions 2. Types of Fraud 3. FWA Trends in Behavioral Health and Medicaid 4. Collaboration

6 FWA Definitions FRAUD Any intentional deception or misrepresentation made by an entity or person in a capitated MCO, Primary Care Case Management, or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting.

7 FWA Definitions ABUSE Any practices in a capitated MCO, Primary Care Case Management program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting.

8 FWA Definitions WASTE Thoughtless or careless expenditure, consumption, mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls.

9 Types of Fraud Falsifying Claims/Encounters Billing for services not rendered Billing separately for services in lieu of an available combination code Misrepresentation of the service/supplies rendered (not accurately documenting or omitting details of the actual services provided, billing for more time or units of service than provided, upcoding) Altering claims Submission of any false data on claims, such as date of service, provider or prescriber of service Duplicate billing for the same service Billing for services provided by unlicensed or unqualified persons

10 Types of Fraud Administrative/Financial Falsifying credentials Fraudulent enrollment practices Fraudulent third-party liability reporting Offering free services in exchange for a recipient's Medical Assistance identification number Providing unnecessary services/overutilization Kickbacks-accepting or making payments for referrals Concealing ownership of related companies

11 Types of Fraud Abuse of Recipients Physical, mental, emotional or sexual abuse Discrimination Neglect Providing substandard or inappropriate care

12 Types of Fraud Denial of Medically Necessary Services Denying access to services Limiting access to services Failure to refer to needed specialist Underutilization

13 Types of Fraud Overutilization of Services Providing unnecessary services Unbundling multiple services Overlapping services Billing for excessive units Documentation does not support the time billed

14 Types of Fraud Recipient FWA Forging or altering prescriptions or orders Using multiple ID cards Loaning his/her ID card Reselling items received through the Medical Assistance program Intentionally receiving excessive drugs, services or supplies

15 FWA Trends in Behavioral Health and Medicaid Billing for services not rendered Community and home based services are vulnerable Misrepresenting of falsifying documentation of the services provided Service does not meet the requirements for the service code Forgery of recipient signatures Treatment plans and encounter forms Falsifying or misrepresenting credentials Credentials do not meet minimum requirements

16 Collaboration = All together, as providers, BH- MCOs, OMHSAS, and BPI, we can help to reduce FWA to decrease wasteful spending in our system.

17 Overview of Regulations

18 Overview of Regulations 1. Federal Regulations 2. State Regulations 3. MCO Requirements (specific to VBH-PA)

19 Federal Regulations Federal False Claims Act (FCA) FCA is federal statute that covers fraud involving any federally funded contract or program, including the Medicare (as well as Medicare Advantage and Medicaid programs. Any individual or organization that knowingly submits a claim he or she knows (or should know) is false and knowingly makes or uses, or causes to be made or used, a false record or statement to have a false claim paid or approved under any federally funded health care program is subject to civil penalties. Potential penalties: Triple damages and penalties between $5,500 and $11,000 for each false claim Exclusion from participating in federally funded programs including Medicare and Medicaid Criminal prosecution

20 Federal Regulations Balanced Budget Act (BBA) Amended Social Security Act (SSA) to include healthcare crimes Must exclude from Medicare and state healthcare programs for those individuals and entities convicted of healthcare offenses Can impose civil monetary penalties for anyone who arranges or contracts with excluded parties

21 Federal Regulations Anti-Kickback Statute A federal law (42 U.S.C. 1320a-7b) that prohibits persons from directly or indirectly offering, providing or receiving kickbacks or bribes in exchange for goods or services covered by Medicare, Medicaid and other federally funded health care programs. These laws prohibit someone from knowingly or willfully offering, paying, seeking or receiving anything of value in return for referring an individual to a provider to receive services, or for recommending purchase of supplies or services that are reimbursable under a government health care program. Violations of the law are punishable by the following: Criminal sanctions including imprisonment and civil monetary penalties. The individual or entity may also be excluded from participating with other federally funded programs, including Medicare and Medicaid.

22 Federal Regulations Fraud Enforcement and Recovery Act of 2009 (FERA) A federal law that increased detection and law enforcement of crimes related to fraud. FERA amended the FCA definition of fraud. FERA infused millions of dollars into law enforcement initiatives to combat fraud in the Medicare and Medicaid programs. FERA included whistle-blower protections.

23 Federal Regulations Patient Protection and Affordable Care Act (PPACA Healthcare Reform Act) A federal law for increased access to healthcare that included provisions specific to fraud and abuse. PPACA increased penalties and enforcement of healthcare crimes. PPACA mandates state and federal agencies to communicate about provider enrollment for federally funded programs. PPACA required Medicare and Medicaid providers to have a compliance program. PPACA reduced the requirements of intent. PPACA stated that overpayments must be reported and returned within 60 days.

24 State Regulations PA Code Chapter 55 Part III. Medical Assistance Manual General Regulations Payment Regulations MA Bulletins

25 State Regulations PA PROMISe PA PROMISe Provider Handbooks ooksandbillingguides/index.htm Mental Health Requirements PA Recovery (for information by level of care)

26 State Regulations PA HealthChoices HealthChoices Behavioral Health Publications lthpublications/index.htm

27 VBH-PA Contract Requirements VBH-PA Provider Manual Fraud and abuse webpage from provider manual - buse.htm

28 VBH-PA Contract Requirements Provider Notifications Provider Online Services pa.com/providers.htm ValueAdded pa.com/provider/value_added_newsletter_archive.htm Mandatory Trainings pa.com/fraud_abuse.htm pa.com/provider/prv_trn.htm Provider Alerts

29 Federal Compliance Program Requirements

30 Compliance Programs Seven Basic Elements of a Compliance Program as Adopted by OIG and CMS 1. Written policies and procedures 2. Compliance Officer and Compliance Committee 3. Effective training and education 4. Effective lines of communication between the Compliance Officer, Board, Executive Management and staff (incl. an anonymous reporting function) 5. Internal monitoring and auditing 6. Disciplinary enforcement 7. Mechanisms for responding to detected problems

31 Compliance Programs New 8th Element of a Compliance Program Compliance Programs Must be Effective Must show that compliance plans are more than a piece of paper Must be able to show an effective program that signifies a proactive approach to the identification of fraud, waste and abuse How much fraud, waste and abuse have you identified? How much fraud, waste and abuse have you prevented?

32 Compliance Programs PA HealthChoices Under PA HealthChoices, all MCOs and providers are required to have compliance programs. VBH-PA reviews compliance programs during program integrity audits with the following assessments completed by the provider prior to the audit: 1. Compliance Program Checklist 2. Internal Controls Assessment

33 Provider Responsibilities

34 Provider Responsibilities 1. Outline of Provider Responsibilities PA Code Provider Manuals 2. Specific FWA Provider Responsibilities Medically Necessary Services Minimum Documentation Requirements Compliance Program Includes self-disclosure requirements

35 Outline: Provider Responsibilities PA Code Provider Responsibilities Medically Necessary Services Provider Prohibited Acts

36 Outline: Provider Responsibilities Provider Manuals VBH-PA = Section IV: Participating Provider Responsibilities pa.com/provider/info/prvmanual/toc.htm PA PROMISe Provider Handbooks ooksandbillingguides/index.htm

37 Specific FWA Provider Responsibilities Medically Necessary Services a. Clarification regarding the definition of medically necessary statement of policy. A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that: (1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. (2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. (3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient and those functional capacities that are appropriate of recipients of the same age.

38 Specific FWA Provider Responsibilities Minimum Documentation Requirements Chapter (e), states that: Providers shall keep records that fully disclose the nature and extent of the services rendered to MA recipients, and that meet the criteria established in this section and additional requirements established in the provider regulations.

39 Specific FWA Provider Responsibilities Minimum Documentation Requirements Chapter (e) states that: The record shall be legible throughout Entries shall be signed and dated by the responsible licensed provider, alterations of the record shall be signed and dated. The record shall indicate the progress at each visit, change in diagnosis, change in treatment, and response to treatment. Progress notes must include the relationship of the services to the treatment plan.

40 Specific FWA Provider Responsibilities Minimum Documentation Requirements According to BPI, each progress note should answer the following questions: Where is the service being provided? Why is the client there? What specific intervention or service was provided to the member? What was the member s response to the interventions? What is the plan for follow-up?

41 Specific FWA Provider Responsibilities Minimum Documentation Requirements VBH-PA Minimum Documentation Requirements Documentation-Standards-for-Payment.pdf Other Treatment Record Requirements VBH-PA Provider Online Services MA Bulletin MA Bulletin , ,

42 Specific FWA Provider Responsibilities Compliance Programs All providers of Medicare and Medicaid are required to have compliance programs. One of the compliance program requirements is selfaudits and disclosures. DPW recommends that providers conduct periodic audits to identify instances where services reimbursed by the MA Program are not in compliance with Program requirements.

43 Specific FWA Provider Responsibilities Benefits of Self-Audit and Disclosure DPW has stated, When a provider properly identifies an inappropriate payment and reports it to the MCO, and the acts underlying such conduct are not fraudulent, DPW will not seek double damages, but will accept repayment without penalty.

44 Specific FWA Provider Responsibilities Benefits of Self-Audit and Disclosure Good faith disclosures and cooperation with OIG and AG can result in the following outcomes: Provides evidence of a robust compliance program Allows for integrity agreements instead of exclusion Allows for lower multiplier and single damages Prevents suspension of future payments Reduces OIG investigations

45 Specific FWA Provider Responsibilities DPW Self- Audit and Disclosure Process: Outlined specific procedures to follow on the following webpage: anceproviderselfauditprotocol/s_ DPW requires providers to return overpayments within 60 days of identifying overpayments For PA HC PSR, providers should conduct self-audits and return overpayments to BH-MCO (VBH-PA) Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered

46 Specific FWA Provider Responsibilities VBH-PA Self- Audit and Disclosure Process: Audit_Referral_Form.pdf

47 Medicaid and BH-MCO Prevention and Detection

48 Prevention and Detection 1. Enforcement Agencies 2. Types of Audits 3. VBH-PA Audits 4. Audit Trends and Findings

49 Enforcement Agencies Federal Centers for Medicare and Medicaid Services (CMS) U.S. Department of Health and Human Services, Office of Inspector General (OIG) U.S. Department of Justice (DOJ) Federal Bureau of Investigation (FBI) Department of Insurance (DOI)

50 Enforcement Agencies State PA Department of State PA Department of Insurance (DOI) PA Attorney General s Office (AG) Medicaid Fraud Control Unit PA Department of Welfare (DPW) Bureau of Program Integrity (BPI) Office of Mental Health and Substance Abuse (OMHSAS)

51 Types of Audits Federal Medicaid Integrity Program (MIP) Medicaid Integrity Group (MIG) Medicaid Integrity Contractors (MIC)

52 Types of Audits State Bureau of Program Integrity Audits BH-MCO Audits (Appendix F requirements under HealthChoices) The Primary Contractor shall designate a Fraud and Abuse Coordinator who will be responsible for preventing, detecting, investigating, and referring suspected fraud and abuse in the HealthChoices behavioral health program to the Department.

53 VBH-PA Program Integrity Audits Routine Audits Scheduled or standard data validation audits, and claims sampling, of contracted providers to ensure compliance with documentation, laws, regulations and billing requirements. The purpose of these audits will also be to monitor providers for possible fraud and abuse. Control assessments, compliance programs, and policies and procedures will be monitored and analyzed for inconsistencies, risk, etc. Audit procedures will be followed for routine audits

54 VBH-PA Program Integrity Audits Audit Procedures Audit notification Pre-audit conference call with provider Entrance meeting with provider for on-site reviews (1st day of audit) Preliminary exit meeting with provider for on-site reviews (last day of audit) Exit conference call with provider Report to provider Provider audit response (CAP or reconsideration)

55 VBH-PA Program Integrity Audits Investigations or allegations of potential fraud and abuse that may involve other oversight entities are NOT routine audits and can deviate from the audit procedures.

56 VBH-PA Program Integrity Audits Minimum Documentation Requirements for Payment Provider-Documentation-Standards-for- Payment.pdf All encounters must have a treatment/service plan, encounter form, and progress notes. All must meet the Minimum Documentation Requirements to receive payment from VBH-PA.

57 VBH-PA Program Integrity Audits Treatment Plan 1. Must be completed according to service requirements 2. Treatment plan date 3. Diagnoses and/or symptoms addressed 4. Clinician s signature, credentials, and signature date 5. Member or guardian s signature and signature date 6. Evidence member or guardian participated with treatment plan development 7. Goals and objectives based on evaluation and mental health strengths and needs 8. Treatment objectives are based of the prescribing and are part of integrated program of therapies, activities, experiences, and appropriate education designed to meet these objectives 9. Treatment goals are measurable 10. Treatment goals have established timeframes 11. Treatment plan addresses less restrictive alternatives that were considered 12. Treatment plan is easy to read and understand 13. Treatment plan documents necessity for services 14. Treatment plan documents the utilization of services

58 VBH-PA Program Integrity Audits Encounter Form 1. Must be completed for each billable encounter (except for services that are excluded from encounter form requirements) 2. Member name including member identification number (as required in the PA Medicaid Bulletin) 3. Type of service 4. Date with start and stop times 5. Total units billed 6. Signature of Member for each encounter 7. Clinician s signature, credentials, and signature date

59 VBH-PA Program Integrity Audits Progress Note 1. Must be completed for each billable encounter 2. Name or Medical Assistance identification number 3. Date of service 4. Start and stop times of service 5. Units match the claims billing 6. Place of service (specific location for community services ) 7. Reason for the session or encounter 8. Treatment goals addressed 9. Current symptoms and behaviors 10. Interventions and response to treatment 11. Next steps and progress in treatment 12. Narrative with the clinical justification to support utilization and time billed 13. Supporting documentation, when applicable 14. Clinician s signature, credentials, and signature date

60 VBH-PA Program Integrity Audits Audit Exceptions Claims Billing Documentation Exceptions and Findings: No progress note No encounter form No services were rendered (no shows) No narrative Progress note was team delivered but billed as separate individual encounters by each team member Progress note is illegible Services provided during the encounter were non-billable Inaccurate units billed Progress note does not provide specific location Progress note does not have start and stop times Progress note is not signed and/or dated by clinician Encounter form is not signed by member, parent, guardian, or agent

61 VBH-PA Program Integrity Audits Audit Exceptions Claims Billing Documentation Exceptions and Findings: Rounding units Services were unbundled and billed individually Overlapping services Encounter form does not include start and stop times Encounter form does not include type of service Encounter form not signed by clinician Correction to note or encounter is not initialed and/or dated Services are bundled in one note (needs to be in separate notes) Progress note or encounter form details (service code, units, time) do not match Incorrect service code or modifier billed Exceeds group size

62 VBH-PA Program Integrity Audits Audit Exceptions Clinical Exceptions and Findings: No valid treatment plan for date of service Incomplete treatment plan for date of service Progress note does not state reason for the encounter Progress note does not state treatment plan goals and objectives Progress note does not reference symptoms or behaviors Progress note does not have next steps in treatment Progress note does not state intervention Progress note or narrative is a duplication or almost a duplication of previous note or narrative Supporting documentation was not attached, when required

63 VBH-PA Program Integrity Audits Audit Exceptions Non-billable activities: Activities that are not included in the service class grid for that particular service code Administrative services as outpatient or any other behavioral health services Transportation Duplicate or overlapping services Member grievance hearings Clinician does not meet requirements to provide service Progress notes that do not fully describe or misrepresent the services provided

64 Q&A Thank you! Please enter questions into webinar or send an to