VNSNY CHOICE HEALTH PLANS FRAUD, WASTE & ABUSE DETECTION MANUAL

Transcription

1 VNSNY CHOICE HEALTH PLANS FRAUD, WASTE & ABUSE DETECTION MANUAL 2014 Developed for use by VNSNY CHOICE officers, directors, managers and staff, including claims, underwriting, member services, utilization and care management, complaint, grievance and appeal and investigative personnel.

2 TABLE OF CONTENTS Page INTRODUCTION.2 I. FWA OVERVIEW 3 II. REPORTING FWA...5 III. INVESTIGATING FWA.. 7 IV. PROACTIVE DETECTION.9 A. OPTUM ENGAGEMENT...10 B. SERVICE VERIFICATION PROCESS...12 VII. AWARENESS AND EDUCATION. 13 VIII. COMPLIANCE COMMITTEE AND REPORTING TO BOARD.. 14 IX. COLLABORATION WITH LAW ENFORCEMENT, OTHER PLANS 15 X. EXCLUSIONS CHECKS AND RELATED MONITORING..16 XI. REVIEW OF MEDICAL RECORDS FOR INVESTIGATION...17 i

3 TO REPORT SUSPECTED FRAUD, WASTE AND ABUSE: Telephone: EthicsPoint Web Portal: (to be activated by March 31, 2014) Write to: VNSNY CHOICE Attention: Director of Compliance 1250 Broadway, 11 th Floor New York, New York

4 INTRODUCTION Fraud, Waste and Abuse ( FWA ) is a significant concern for VNSNY CHOICE and the entire health insurance industry, including Medicare Advantage and Medicaid managed care programs. The National Health Care Anti-Fraud Association (the NHCAA ) conservatively estimated that three percent of what Americans spend annually on health care is lost to fraud. 1 The Government Accountability Office ( GAO ) estimated that for fiscal year 2011 improper payments by Medicare and Medicaid programs totaled $64.8 billion, and that improper payments in the Medicare Advantage alone accounted for $12.4 billion. 2 The New York State Office of the Medicaid Inspector General ( OMIG ) reported that in 2012 it recovered more than $468 million in improperly spent Medicaid funds. 3 As the costs of health care rise, FWA prevention and detection is critical to ensuring continued coverage for New Yorkers who rely on Medicare and Medicaid, over 3 million and over 5.5 million enrollees, respectively. This Fraud, Waste and Abuse Detection Manual outlines how everyone at VNSNY CHOICE can do their part to address FWA, and describes the robust systems VNSNY CHOICE has in place, and in implementation, to detect and investigate FWA. 1 Testimony of the National Health Care Anti-Fraud Association to the House Insurance Committee House of Representatives, Commonwealth of Pennsylvania, January 28, 2010 ( 2 Government Accountability Office, Improper Payments: Remaining Challenges and Strategies for Government-wide Reduction Efforts, GAO T (March 28, 2012). 3 New York State Office of the Medicaid Inspector General Annual Report (2012) ( 2

5 I. FRAUD, WASTE AND ABUSE OVERVIEW 1. What is Fraud Waste and Abuse? Fraud is an intentional deception, concealment or misrepresentation made by someone with knowledge that the deception will result in benefit or financial gain. Waste includes any practice that results in an unnecessary use or consumption of financial or medical resources. Waste does not necessarily involve personal gain, but often signifies poor management decisions, practices or controls. Abuse is a practice that is inconsistent with accepted business, financial or medical practices or standards and that results in unnecessary cost or in reimbursement. Together, Fraud, Waste and Abuse are often referred to as FWA. Examples of FWA include: By providers: o Billing for services not provided; o Deliberately filing incorrect diagnosis or procedure codes to maximize payment for claims; o Quality of care issues; o Failure to maintain adequate medical records; o Cover-ups in coordination of benefits; o Misrepresenting services or dates of service; o Billing non-covered services as covered services; o An eligible provider billing for services provided by a non-eligible provider or individual; o Providing and billing for unnecessary services; or o Accepting or offering kickbacks and bribery. By members: o Loaning a VNSNY CHOICE identification card for use by another person; o Altering the amount or date of service on a claim form or prescription receipt; o Fabricating claims; or 3

6 o Doctor shopping (seeing several providers to obtain frequent drug prescriptions) and excessive trips to the emergency room for narcotics. By non-members: o Using a stolen VNSNY CHOICE card to obtain medical services or prescriptions; or o Engaging in impermissible sales and marketing practices to steer potential members to or from VNSNY CHOICE plans. By VNSNY CHOICE employees: o Creating claims; o Delaying assignment of a provider to reduce costs; o Failing to provide covered services to reduce costs; o Engaging in impermissible sales and marketing practices, such as using unapproved promotional materials, falsifying eligibility information, enrolling individuals without their knowledge or offering inducements to members and providers to join; or o Changing member or provider addresses to intercept payments. 4

7 II. REPORTING FRAUD, WASTE AND ABUSE If any VNSNY CHOICE employee, director, officer, contractor or other person affiliated with VNSNY CHOICE suspects FWA, that person is required to report the suspected FWA. A report of suspected FWA may be made directly to the Compliance Department Special Investigations Unit via: Compliance Hotline: CHOICECompliance@vnsny.org EthicsPoint Web Portal: (to be activated by March 31, 2014) Mail: VNSNY CHOICE, Attention: Director of Compliance, 1250 Broadway, 11 th Floor, New York, New York Anyone who reports FWA may remain anonymous. All information received or discovered will be treated as confidential, and the results of investigations will be discussed only with persons having a legitimate reason to receive the information (e.g., state and federal authorities, VNSNY legal department, medical directors and/or senior management). VNSNY CHOICE has a strict policy of no retaliation against, or intimidation of, anyone who in good faith reports suspected FWA or a compliance issue. Potential FWA cases can be identified or received by the VNSNY CHOICE Special Investigations Unit ( SIU ) through a variety of mechanisms, including, but not limited to: verbally or in writing from employees, directors, officers, providers, vendors, consultants, members, caregivers, First-tier, Downstream and Related Entities ( FDRs ), and the public; via the anonymous CHOICE Compliance Hotline: , CHOICECompliance@vnsny.org, or the EthicsPoint web portal: (to be activated on March 31, 2014); through a referral from law enforcement or regulatory agencies; through referral from another department involved in the analysis of member or provider claims, billing and payment patterns, as well as third parties contracted by VNSNY CHOICE to conduct analyses; through a referral from another department involved in authorizing services or monitoring utilization by members, such as Medical Management, the Medical Directors, or VNSNY CHOICE regional clinical staff; through a referral from the Grievance & Appeals Department identified during the investigation of a grievance, complaint, or appeal; 5

8 through a referral from Quality Management identified during the investigation of a quality of care concern; through a referral from the Provider Network Development Department identified during the investigation of a provider complaint; through a referral from a FDR, including providers; through a referral from the member services Call Center, or member retention unit; through a referral from any person or entity listed in the VNSNY Corporate Policy: Reporting Non-Compliance and Fraud, Waste and Abuse; or through a referral from any department or affiliate of VNSNY CHOICE. 6

9 1. Investigation Procedures III. INVESTIGATING FRAUD, WASTE AND ABUSE The SIU investigates all reports of suspected FWA in accordance with VNSNY CHOICE Policies and Procedure: Special Investigations Unit and Fraud Waste and Abuse, and the VNSNY Corporate Policy: Investigating Compliance Issues and Corrective Action Plans. Investigations are assigned to a Special Investigator ( SI ) who is responsible for conducting investigations in a timely manner. The SI logs the investigation in the SIU Database, noting the date the report was received, establishes a case file, and sends an acknowledgement to the source of the report, if appropriate. (Note: In the case of FWA referrals from Grievance & Appeals, the Grievance & Appeals Department provides acknowledgment of receipt, and notice of resolution, of complaints and grievances, to the member or member representative.) The SI researches the validity of the report and obtains all necessary supporting documentation for the case file, including reviews of provider and member claims history, reviews of billing and/or payment history or patterns, reviews of prescribing/ordering history, reviews of medical records, on-site review or monitoring of a provider office, interviews with providers and/or members and review of provider and/or member contacts with VNSNY CHOICE. Investigations are to be commenced within three (3) business days following the receipt of a report of potential FWA. The SI makes best efforts to close any investigation, if possible, within thirty (30) days of the receipt date, and must close all investigations according to timeframes required by applicable state or federal laws or regulations, and internal deadlines set by VNSNY CHOICE operational areas. VNSNY CHOICE operational areas must refer investigations to SIU promptly and with reasonable time to meet applicable regulatory deadlines. In some cases, the SI may be granted an extension for good cause shown. 2. Reporting to State and Federal Agencies The SIU notifies applicable federal and state agencies, including law enforcement as appropriate, of suspected FWA, including but not limited to the U.S. Department of Health and Human Services Office of Inspector General ( OIG ) and the OMIG. If the SIU determines that potential fraud or misconduct related to the Part D program has occurred, the SIU reports conduct to the National Benefit Integrity Medicare Drug Integrity Contractor ( NBI MEDIC ) promptly, but no later than sixty (60) days after the determination that a violation may have occurred. To the extent that potential fraud is discovered at the FDR level, the SIU refers the conduct to the NBI MEDIC sooner, as appropriate, so that the NBI MEDIC can help identify and address any schemes. 7

10 For each case of FWA confirmed by the SIU, the VNSNY CHOICE Compliance Department reports to New York State Department of Health ( NYSDOH ) on an ongoing basis the following information when the case is confirmed: The name of the individual or entity that committed the FWA; The source that identified the FWA; The type of provider, entity or organization that committed the FWA; A description of the FWA; The approximate range of dollars involved; The legal and administrative disposition of the case, including actions taken by law enforcement officials to whom the case has been referred; and Other data/information as prescribed by NYSDOH. The Compliance Department also files an annual report with NYSDOH no later than January 15 of each year describing VNSNY CHOICE s experience, performance and efficiency in implementing its fraud and abuse prevention plan and proposals for improving the fraud and abuse prevention plan. VNSNY CHOICE also reports at least annually the number of FWA complaints made to VNSNY CHOICE each year, and includes the information listed in the bullets above for each. 8

11 IV. PROACTIVE DETECTION OF FRAUD, WASTE AND ABUSE VNSNY CHOICE devotes significant resources and effort to proactive detection of potential Fraud, Waste and Abuse, and has developed key initiatives and processes aimed at proactively detecting patterns and practices of FWA. An engagement with OptumInsight, Inc. ( Optum ) to perform retrospective detection and investigation services, using proprietary techniques to identify potential fraudulent billing practices. The contract also provides for Optum to investigate potential FWA in certain cases, and to refer other potential FWA cases to the SIU for investigation. The SIU oversees all such oversight and investigation activities and ensures that the contract for services complies with applicable State and Federal laws and regulations (see Section IV.A of this Manual); A service verification process including telephonic outreach on a quarterly basis to a statistically significant sample of members with claims for recent dates of service, to confirm they received medical services billed and followup investigation by SIU as appropriate (see Section IV.B of this Manual); Using Medicare National Correct Coding Initiative ( NCCI ) claim coding edits to identify waste and prevent improper payments; Employment of advanced analytics by SIU, specifically the SAS statistical analysis system, in conjunction with the VNSNY CHOICE Data Warehouse to evaluate outliers and potential FWA patterns; and The SIU also conducts education and awareness training efforts in order to maximize the amount of referrals from employees, directors, officers, contractors, agents, providers and FDRs (see Section V of this Manual). 9

12 IV.A OPTUM ENGAGEMENT VNSNY CHOICE has engaged with Optum to perform retrospective detection and investigation services, using proprietary techniques to identify potential fraudulent billing practices. A project team including the SIU and Information Technology is steering implementation, with the first data run and delivery to the SIU expected at the start of the 3 rd quarter of SIU will oversee the contract and open investigations based on patterns identified by Optum. The contract also provides for Optum to investigate potential FWA in certain cases, and to refer other potential FWA cases to the SIU for investigation. A timeline of the project implementation as of March 7, 2014 is below. Milestone Target Date Responsible Status High-Level Requirements 01/24 VNSNY Complete Analysis and High Level Process Complete Flow Defined 02/07 Optum Detailed Requirements 02/07 VNSNY Complete Mapping CCDI Detailed In progress Extract Program Design 02/28 VNSNY Development of Extract Programs 03/21 VNSNY Unit Test of Extract Programs 04/04 VNSNY Test Cases for Testing (System and UAT) 03/28 VNSNY & Optum ECG Set up ( Secure File Transfer) TEST Connection 03/14 VNSNY & Optum First Test File to Optum 04/04 VNSNY Complete System Testing w Optum CCDI Team (System testing) 04/18 VNSNY & Optum VNSNY Extract meets CCDI Layout + First Integration File to Optum 04/18 VNSNY Integration Testing Start - Cycle 1 04/21 VNSNY & Optum Integration Testing End - Cycle 105/09 VNSNY & Optum Integration Testing Start - Cycle 2 (UAT) 05/13 VNSNY & Optum Integration Testing End - Cycle 2 (UAT) 05/26 VNSNY & Optum Integration Testing Start - Cycle 3 (UAT) 05/18 VNSNY & Optum Integration Testing End - Cycle 3 (UAT) 06/06 VNSNY & Optum 10

13 Complete Ops Readiness activities (P&P and SOP Updates) 05/20 VNSNY & Optum Go-No/Go Decision - Historical 06/09 VNSNY & Optum History Extract - 36 Months of Claims and send it Optum 06/16 VNSNY History Load - 36 Months of Claims 06/23 Optum DMQ Run and Share Results w VNSNY 07/18 Optum 11

14 IV.B. SERVICE VERIFICATION PROCESS VNSNY CHOICE has implemented a Service Verification Process ( SVP ) to verify with its members that services billed by providers were received. On a quarterly basis, the SVP verifies the delivery of billed services to its members by pulling statistically valid claims samples and contacting members to confirm services billed in fact were received. When members report that billed services were not received, the SIU investigates and takes appropriate corrective action, as necessary. The process has been implemented for VNSNY CHOICE s SelectHealth ( HIV SNP ) product, and is planned to be implemented for other lines of business starting the 2 nd quarter of To track the process, the VNSNY CHOICE Compliance Department has loaded this requirement as an indicator into its Online Monitoring Tool ( OMT ), which notifies the Health Economics Department to generate the report, pull the sample and give feedback on both the claims chosen and the number of members identified for outreach. A second OMT indicator has been set up for the VNSNY CHOICE Call Center to provide the SVP a call outcome report with the number of members reached and the results of outreach with the members. The indicator also records follow-ups by SIU, including notations on investigations opened based on the SVP calls. 12

15 VII. AWARENESS AND EDUCATION VNSNY CHOICE employs a variety of approaches to promote the awareness and the education of employees and delegated entities about FWA: Starting in 1 st quarter 2014, the SIU is rolling out a FWA webpage accessible and publicized to employees, FDRs, members, providers, and the public, including trends and hot topics in FWA, tips on how to detect FWA, and information on reporting. The web page will be a source for regular, varied and continuous training on FWA. Examples of content include news about recent fraud schemes and advice to members to review their Explanation of Benefits and report any services they believe they did not receive. FDRs that perform operational services on behalf of VNSNY CHOICE, including the pharmacy benefits manager and third-party administrator, attest yearly that they have provided FWA training to their employees and contractors. The SIU works with FDRs special investigation units and audit departments to investigate FWA reports, to share information about individual cases or fraud schemes of common concern, and to coordinate responses when potential trends or patterns are identified. The VNSNY CHOICE Compliance Department and the SIU perform formal and informal trainings throughout the year. In September 2013, VNSNY launched its Compliance Awareness Campaign to introduce its enhanced Compliance Program and Code of Conduct. In the months following, Compliance Department and SIU representatives led training and awareness events at all VNSNY locations, with specific content on FWA, including reporting and detection. In May 2014, Compliance Week will include multiple FWA awareness and training communications as well as in-person events. The Compliance Department and leadership maintain an open-door policy to communicate compliance concerns, suspected code of conduct violations, and suspected FWA, and this open-door policy is emphasized at every training opportunity. SIU staff receives specialized training on investigation techniques and VNSNY systems, including SAS and access to the Data Warehouse, as well as attend national conferences on latest developments in Compliance and FWA. Starting in 2014, SIs are expected to attend NHCAA education and training programs, and attend conferences to monitor recent developments and strengthen coordination with law enforcement agencies. 13

16 VIII. COMPLIANCE COMMITTEE AND REPORTING TO BOARD The SIU reports on FWA and its investigation activities on a quarterly basis to the VNSNY CHOICE Compliance Committee. FWA issues are reported to the Audit Committee of the VNSNY Board of Directors, also on a quarterly basis. The SIU reports on the trends and patterns, as well as the outcomes, including corrective actions and recoupment, of all FWA investigations to the Compliance Committee. Starting in 2014, reporting will include the financial impact of claims issues investigated, as well as the estimated savings to VNSNY CHOICE due to changes in billing behavior in response to SIU actions. The VNSNY CHOICE Fraud Plan is submitted to the Audit Committee of the VNSNY Board of Directors annually for review. 2

17 IX. COLLABORATION WITH LAW ENFORCEMENT AND OTHER HEALTH PLANS SIU staff are in regular contact with the OMIG at the investigative level to report suspected FWA and to coordinate on an ongoing basis regarding investigations as well as audits. SIU staff similarly have regular contact with the NBI MEDIC to report and coordinate on reports and investigations of suspected FWA. Starting in 2014, SIU staff are also will attend New York task force events to share information on patterns and trends of FWA, and establish further contacts with law enforcement, as well as other health plans. The SIU coordinates with other health plans special investigation units to share information on investigations, particularly when a scheme common to the plans vendors or providers is suspected. 3

18 X. EXCLUSIONS CHECKS AND RELATED MONITORING VNSNY CHOICE performs monthly checks of all employees against exclusionary lists to ensure that it does not hire or employ persons who have committed FWA or present a program integrity concern. The exclusionary lists include: the List of Excluded Individuals and Entities ( LEIE ), the Excluded Parties System ( EPLS ), Social Security Administration Death Master File and the National Plan Provide Enumeration System ( NPPES ). Any checks that raise a potential concern, or that involve a question of correct identity are escalated to VNSNY Corporate Compliance. VNSNY CHOICE also checks new providers and re-enrolled providers against excluded provider lists, including: the LEIE, the EPLS, Social Security Administration Death Master File and the NPPES, including monthly verifications on all participating providers. All network providers are required by contact to monitor staff and managing employees against the above exclusionary lists and report any exclusions to VNSNY CHOICE on a monthly basis. Potential issues identified by provider checks are monitored through reports to the CHOICE Compliance Department and the SIU. VNSNY CHOICE collects ownership and control disclosure information from managing employees for conflict of interest purposes, as well as from contracted entities at regular intervals. 4

19 XI. REVIEW OF MEDICAL RECORDS FOR INVESTIGATION Upon receiving a report or detecting a pattern or practice of potential FWA, the SIU conducts a review of all available internal records and systems, including authorizations, care management and claims as appropriate. Based on the review, the SIU determines the need and scope of a request for medical records, and requests records based on the workflow and templates included in the subheadings below. Once obtained, the medical records are reviewed by SIU staff with coding experience and, as necessary, by Medical Directors or other clinicians for quality of care issues as well as appropriateness of services provided. Upon reasonable suspicion, any FWA or quality of care issues are referred to the OMIG, OIG and the NBI MEDIC, if applicable. Upon a finding of FWA, a letter requesting recoupment is sent, and the referral to the relevant government agencies is supplemented with a summary of the findings. VNSNY CHOICE makes concerted efforts to recover all overpayments associated with a finding of FWA. 1. Medical Records Request Work Flow a. First Medical Records Request i. Use the medical records request letter template below and send via certified mail: 1. The provider is given 20 days to respond. 2. Document the date the letter is sent in the investigation report. 3. Upon sending the initial medical records request, send an to the Vice President of Network Development and Contracting; the Director of Network Development and Contracting; and the Director of Provider Relations and Network Development. The should include the name of the provider and the date the medical records request was sent. The should also state the provider can be directed to the assigned investigator, should they have any questions regarding the medical records request. 4. If you have not already done so, a copy of the provider s contract (Physician Agreement) should be requested at this time. ii. If medical records are received: 1. Stamp the receipt date on the medical records. 2. Document the receipt date in the investigative report. 3. Scan the records and upload to the investigation folder. 4. Review medical records and document findings in the investigation report. 17

20 5. If necessary, forward the medical records to a nurse/medical director for further review. a. Once review is completed by the nurse/medical director, document their findings in the investigation report. 6. If the medical records review returns no actionable items, continue the investigation as needed or if warranted, close the investigation. 7. If the medical records review yields actionable recommendations, meet with management team to decide what administrative actions are necessary. 8. Implement the recommended administrative actions. Continue the investigation as needed or if warranted, close the investigation. iii. If medical records are not received within the allotted time, proceed to Section XI.1.b of the work flow. b. Second Medical Records Request: i. Use the follow-up medical records request letter template below and send via certified mail: 1. The provider is given 15 days to respond. 2. Document the date the letter is sent in the investigation report. ii. If medical records are received: 1. Refer to Section XI.1.a and proceed with actions listed under step ii. iii. If medical records are not received within the allotted time, proceed to Section XI.1.c of the work flow. c. Final Medical Records Request: i. Use the follow-up medical records request letter template (below) and send via certified mail: 1. The provider is given 15 days to respond. 2. Document the date the letter is sent in the investigation report. ii. If medical records are received: 1. Refer to Section XI.1.a and proceed with actions listed under step ii. 18

21 iii. This is the final attempt at obtaining medical records from a provider. Failure to submit the requested information could subject the provider to one or multiple administrative actions being taken by the plan. The SIU, in conjunction with other relevant departments, will determine what administrative actions are warranted and necessary pursuant to the physician agreement ratified by the provider and VNSNY CHOICE. d. Administrative Actions: i. Once the SIU and all relevant departments have agreed upon the appropriate administrative action(s) to be taken against the provider, the Compliance Department will submit a recommendation to the Credentialing Committee. This recommendation will contain the course of action agreed upon by all relevant departments. ii. The SIU may independently pursue other actions as a result of investigative findings. These actions include: 1. Reporting to external agencies such as the OMIG, the OIG, the NBI-MEDIC, Licensing Boards, etc; 2. Overpayment recovery, in coordination with the Claims Department; 3. Provider education (through a Corrective Action Plan or CAP ), in coordination with the Provider Relations Department; and/or 4. Monitor provider billing activity for a predetermined period, to ensure effective implementation of CAP. 19

22 [CHOICE Letterhead] [Date] [Provider Name Provider Address] PROVIDER NUMBER: Medical Records Request Template First Request Re: VNSNY CHOICE Special Investigations Unit Request for Medical Records Dear XXXXX: The VNSNY CHOICE Special Investigations Unit ( SIU ) is conducting a medical review of your billing for services provided to our members. Pursuant to federal and state law, the SIU is charged with investigating potential fraud, waste and abuse. You were selected for this review because [insert reason, for example: our analysis of your billing data indicates that you may be billing inappropriately for services]. We have selected a [optional: random sample] sample of claims for services provided during the period through. (See attached listing.) For each of these claims, we are requesting [full medical records / the following information:] [The following list is for illustrative purposes. The SIU should request any documentation that will permit them to conduct a thorough review of the claims submitted with regard to coverage, eligibility, medical reasonableness and necessity, etc.] [ Form HCFA-485; Form HCFA-486, or equivalent information, if applicable; Form HCFA-487, or equivalent information, if applicable; Flow sheets or treatment sheets, if used; Narrative or progress notes, if used; Supplemental order, if applicable; Itemized breakdown of supplies, if supplies are billed; Lab values, if applicable; Copy of the UB-92 for each bill; Lab reports for any B12 injections; Lab or x-ray reports for any calcimar injection; 20

23 Other ] [The Physician Agreement should be verified, case by case, to ensure the following contract language applies: As a participating provider, you are required to provide the documentation requested by VNSNY CHOICE, in accordance with Article II, Sections 5-8 of the VNSNY CHOICE Physician Agreement.] The above information should be mailed to the following address within 20 days from the date of this letter: VNSNY CHOICE Health Plan, 1250 Broadway, 11th Floor, New York, NY ATTENTION: [INVESTIGATOR NAME]. The SIU, and as necessary, in coordination with medical staff, will review the documentation you submit to determine if the services billed are reasonable and necessary and meet all other contractual requirements. [Optional: If/Should the review result in any adverse determination, you will receive written notification containing the following information: A listing of the claims that were reviewed and our determinations with regard to those claims (i.e., full or partial denials), the specific reasons for denial, an explanation of why you are responsible for the incorrect payment, the amount of the overpayment or underpayment, and interest accrual on unpaid balances.] If you have any questions concerning this request, you may contact me at [Investigator telephone number]. Your cooperation is appreciated. Sincerely, [Investigator Name] Special Investigator VNSNY CHOICE Health Plans Enclosure: Listing of Sample Claims Requiring Medical Documentation 21

24 [CHOICE Letterhead] [Date] Medical Records Request Template Second/Final Request [SECOND/FINAL] REQUEST RESPOND IMMEDIATELY [Provider Name Provider Address] PROVIDER NUMBER: Re: VNSNY CHOICE Special Investigations Unit Request for Medical Records Dear XXXXX: On [date], the VNSNY CHOICE Special Investigations Unit ( SIU ) sent you letters requesting records necessary to conduct a medical review of your billing for services provided to our members. Pursuant to federal and state law, the SIU is charged with investigating potential fraud, waste and abuse. As of the date this letter was sent, we have not received the records requested. It is critical to respond to this request within 15 days. The information should be mailed to the following address: VNSNY CHOICE Health Plan, 1250 Broadway, 11th Floor, New York, NY ATTENTION: [INVESTIGATOR NAME]. A copy of the initial request is enclosed for your reference. Failure to respond to this request will lead to further action pursuant your contract with VNSNY CHOICE. If you have any questions concerning this request, you may contact me at [Investigator telephone number]. Your cooperation is appreciated. Sincerely, [Investigator Name] Special Investigator VNSNY CHOICE Health Plans Enclosure: First Request Letter (with attachments) 22