SUSPICIOUS ACTIVITY DETECTION AND BILLING INVESTIGATIONS

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1 SUSPICIOUS ACTIVITY DETECTION AND BILLING INVESTIGATIONS New Mexico Medicaid False Claims Act OptumHealth has four core modules related to Recovery and Resiliency. These programs provide an overview of Recovery and Resiliency including self-directed care, history and challenges of the movement. In addition, best practices (evidence-based, professional guidelines and consumer-driven elements) will be addressed along with barriers to, and support for, the Recovery and Resiliency movement. These core modules will support the efforts of all stakeholders to act upon and continuously improve current Recovery and Resiliency goals and objectives. In addition to these core offerings, we will provide additional learning opportunities on such topics as consumer and family engagement, traditional healers and cultural preferences, and consumer rights and responsibilities. There will also be a range of clinical and therapeutic intervention topics covered. Please check the Provider Portal regularly to see upcoming trainings. Deficit Reduction Act The Deficit Reduction Act of 2005 (DRA) contains a provision entitled Employee Education About False Claims Recoveries ( 6032), which requires that an organization that annually receives $5 million in Medicaid payments (Qualifying Entities) to establish written policies and procedures about federal and state false claims laws and whistleblower protections [Note: the State of New Mexico has established thresholds different from the $5 million for any payer since the regulations apply to total Medicaid payments from all payers]. In addition, the DRA requires Qualifying Entities to include those policies and procedures in their employee handbooks. Policies and procedures and employee handbooks for Qualifying Entities must include information regarding: The Federal False Claims Act New Mexico False Claims Act Administrative remedies for false claims and statements; and Whistleblower protections under the law Failure to comply with these educational requirements may render a Qualifying Entity ineligible to receive Medicaid payments and other penalties and/or sanctions as contained in the DRA. In accordance with the legislation, the New Mexico Human Services Department (HSD) requires OHNM to ensure that all Qualifying Entities that receive more than $3 million a year from OptumHealth are in compliance with this requirement. Therefore, OptumHealth requires all Qualifying Entities who receive more than $3 million a year either to adopt the OptumHealth Policy and Procedure on Fraud, Waste, and Abuse Prevention and Detection Program, which will be posted on the OptumHealth provider portal or a similar policy. The Qualifying Entity is required to provide a written attestation that the required training has occurred and is part of the Qualifying Entity s employee handbook and training materials. OptumHealth will provide a copy of a sample attestation letter to all Qualifying Entities that meet the payment threshold. The State of New Mexico requires this attestation be completed annually. 41

2 Billing & Audit Process It is the policy of OHNM to require employees, contractors, and providers to report any suspected incidents of fraud, waste, and/or abuse to OptumHealth, HSD/MAD, and applicable state agencies. Failure to report potential or suspected fraud, waste, and/or abuse may result in sanctions, contract cancellation, or exclusion from participation in the program. OptumHealth has established a comprehensive Fraud, Waste, Abuse Prevention and Detection Program on both company-wide and departmental specific levels. These departments ensure the monitoring of employee and provider business practices for instances of fraud, waste, and/or abuse, and the proper reporting of such instances. This program is based upon standard OptumHealth, United Behavioral Health, and Ingenix company policies for identifying and addressing suspected fraud, waste, and abuse and has been modified to meet regulatory requirements of the State of New Mexico, as outlined in NMAC as well as other applicable requirements of the New Mexico Interagency Behavioral Health Purchasing Collaborative ( Behavioral Health Collaborative ) and other state agencies. The OptumHealth Fraud, Waste, Abuse Prevention and Detection Program addresses the detection, investigation, and reporting of fraudulent, wasteful and/or abusive practices. Such practices include, but are not limited to, filing fraudulent claims, fraudulent authorization of claims, misrepresentation of services provided, abuse of services, misrepresentation of a person s identity or other material fact, and violations of State or Federal laws in order to obtain a benefit (including personal or commercial gain) from OptumHealth to which an individual or entity is not entitled. The Fraud, Waste, and Abuse Prevention and Detection Program operates under the following State and Federal Definitions. Abuse: in the context of billing provider practices that are inconsistent with sound fiscal, business, medical or service related practices and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards for healthcare. Fraud: is an intentional deception or misrepresentation by a person or an entity with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable federal or state law and with NMAC Waste: is the allocation or expenditure of resources significantly in excess of the need for the principal purpose of person or commercial gain. Examples of fraud, abuse, and waste are: Inappropriate balance billing Inadequate resolution of overpayments Lack of integrity in computer systems Failure to maintain confidentiality of information/records High utilization of procedures or tests not medically necessary Providing services that are not medically necessary Providing poor quality medical services Unbundling/exploding charges (e.g., unpacking and billing separately of services that would ordinarily be all-inclusive) Coding a service at a higher level than what was rendered, i.e., upcoding Breaches of Participation Agreement that result in Consumers being billed for amounts not allowed by OptumHealth Failure to collect and/or report coinsurance and deductible amounts Excessive charges for services 42

3 Inappropriate documentation of services rendered Paying, soliciting, offering, or receiving: o A kickback or bribe in connection with the furnishing of treatment, services or goods for which payment is or may be made in whole or in part under the Medicaid program; o A rebate of a fee or charge made to a provider for referring a Consumer to a provider, or o Anything of value, with intent to retain it, and knowing it to be in excess of amounts authorized or rates established under the Medicaid program, as a precondition of providing treatment, care, services or goods or as a requirement for continued provision of treatment, care, services, or goods. Providing the following with the intent that the claim be relied upon for the expenditure of public money: o Treatment, services, or goods that have not been ordered by a treating provider o Treatment that is substantially inadequate when compared to generally recognized standards with the profession or industry, or o Merchandise that has been adulterated, debased, mislabeled, or is outdated. Presenting or causing to be presented for allowance or payments with intent that a claim be relied upon for the expenditure of public money, any false, fraudulent, excessive, multiple, or incomplete claims for furnishing treatment, services, or goods. OptumHealth New Mexico uses multiple methods of detection: Focused Audits Claim Audits Retrospective Review Encounter Audits Provider profiling and credentialing Medical Review, Utilization and Quality Management Review Corporate Integrity and Compliance Program Consumer issues, concerns and complaints (through tipline on website and phone) Referrals from HSD, the Behavioral Health Collaborative, and other governmental entities Consumer and provider issues and complaints are monitored for issues related to potential fraud, waste, and abuse by the Program Integrity Unit of OHNM. Consumer and provider complaints are investigated and reported to the Fraud & Abuse Committee. The detection and investigation of potential fraud, waste, and abuse related to claim payments, provider billing practices and utilization patterns are also investigated by the OptumHealth Program Integrity Unit and reported to the Fraud & Abuse Committee and to interested state agencies. 43

4 Investigation and Reporting Processes 1. The Program Integrity Unit leads all investigations into any alleged incidents of fraud, waste, or abuse and compiles provider or member reports. 2. The Compliance Director reports any potential cases of fraud, waste, and abuse to the Collaborative, HSD/MAD, the New Mexico Behavioral Health Collaborative, and/or the New Mexico Medicaid Fraud Control Unit of the Attorney General s Office (MFCU), as required by contract, rules, and regulations. 3. OptumHealth reports to HSD/MAD the names of all providers identified with aberrant utilization, according to results of provider profiling, regardless of the cause of the aberrancy. 4. The OHNM Director of Compliance provides quarterly reports related to fraud, waste, and abuse to the Quality Management/Quality Improvement (QM/QI) Council to ensure that fraud, waste, and abuse issues are incorporated into the overall Quality Management Program. In addition, the Director of Compliance will be a member of the QM/QI Council. 5. All employees are required to report any suspected incidents of fraud, waste, and/or abuse to the OptumHealth Tipline. Contractors and providers are to report any incidents of alleged fraud, waste, and/or abuse. 6. OptumHealth maintains the following documentation: Date of occurrence Individual reporting the incident (if available) Date incident was reported Name of suspected provider or practitioner (if applicable) Name of suspected member (if applicable) Description of the incident Date reported to Ingenix (if applicable) Person at Ingenix reported to Date reported to the state Person at the state to whom report is made, as applicable Date other agencies notified, as applicable Resolution by New Mexico MFCU, as indicated 7. If the findings of a preliminary investigation give reason to believe there was an incident of fraud, waste, and/or abuse, the Collaborative may forward the case to MFCU of the New Mexico Office of Inspector General, who manages the medical account for the Centers for Medicare and Medicaid Services (CMS). A referral to this agency does not always mean that a provider will be prosecuted. However, OptumHealth cooperates fully with any and all requests from MFCU and other investigatory agencies, in accordance with applicable laws. a) OptumHealth complies with all requirements of the CMS Medicaid Integrity Program and the Deficit Reduction Act of b) OptumHealth will cooperate with and assist the New Mexico MFCU and any state or federal agencies charged with the duties of identifying, investigating, sanctioning, or prosecuting suspected fraud, waste, and/or abuse. c) The Program Integrity Unit will report fraud, waste, and/or abuse to the OHNM Fraud & Abuse Committee for review and recommendation. d) Contact information for the New Mexico Medicaid Fraud Control Unit is: 44

5 Medicaid Fraud Control Unit of New Mexico Office of the Attorney General 111 Lomas Blvd. NW, Suite 300 Albuquerque, NM phone: fax: OptumHealth New Mexico Practitioners and Providers Practitioners and providers are contractually obligated to cooperate in all investigations of potential fraud, waste, and abuse cases. OptumHealth policies and procedures regarding the detection and reporting of fraud, waste, and abuse are available on the OHNM provider portal. Providers are informed of changes to the Fraud, Waste, and Abuse Prevention and Detection Program through provider newsletters, special mailings, provider/practitioner trainings, and the OHNM provider portal. Provider Non-compliance OHNM respects its partnership with its network providers and will work with providers to handle fraud, waste, and abuse cases. Failure to comply with a fraud, waste, and/or abuse investigation may result in the following, as appropriate: Network Termination when issues of abusive or inappropriate billings are not resolved, OHNM will recommend immediate termination of the subject provider from our network. State and/or federal referral OHNM will report any suspicion or knowledge of fraud, waste, and/or abuse that requires an external investigation to the appropriate authorities. OHNM will cooperate fully in any investigation or subsequent legal action that may result from such investigation. OHNM and its providers are required to make available to investigators any administrative, financial, and medical records such investigators may require. OptumHealth New Mexico Consumer Upon enrollment, every OptumHealth New Mexico consumer receives a consumer handbook that includes information regarding fraud, waste, and abuse, including instructions on how to detect and report situations of potential fraud, waste, or abuse. The consumer newsletter periodically addresses topics regarding fraud, waste, and abuse. Eliminating Fraud and Abuse To eliminate fraud, waste, and abuse successfully, providers, facilities, and consumers must work together to prevent and identify inappropriate and potentially fraudulent billings. This can occur by: Monitoring claims submitted for compliance with billing practices Adherence by providers and facilities to treatment record standards 45

6 Education of all staff responsible for dealing with medical records (including documentation, storage, retrieval, or review) or who are involved with billing Referring cases of suspected fraud and abuse. For more healthcare fraud, waste, and abuse information in New Mexico, visit the following sites. New Mexico Medicaid Fraud Control Unit 407 Galisteo Street Bataan Memorial Building, Room 260 Santa Fe, NM Toll free client information: New Mexico Human Services Department of Medical Assistance Division NM Human Services Department Medical Assistance Division P. O. Box 2348 Santa Fe, NM main phone: toll free client information: fax: or to report medicaid fraud, the Quality Assurance Bureau at 46