Program Integrity Fraud, Waste, and Abuse Training

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1 Program Integrity Fraud, Waste, and Abuse Training March 2015 Jim K. Hampton, Director Fraud Operations & SIU

2 Health Care Fraud is a crime that has a significant effect on the private and public health care payment system. Fraud & Abuse accounts for over 10% of annual health care costs. Taxpayers pay higher taxes because of fraud in public programs such as Medicaid and Medicare. Purpose Recognizing the serious implications of improper payment resulting from fraud & abuse, PerformCare Fraud & Abuse Program is dedicated to detecting, investigating and preventing all forms of suspicious activities related to possible health care fraud & abuse, including any reasonable belief fraud and/or abuse will be, is being, or has been committed. 1

3 This training will provide answers to the following questions: Overview What is Fraud and Abuse? What are the types of Fraud? What are potential Fraud indicators? What laws regulate Fraud & Abuse? What is a Fraud & Abuse violation? How is suspicious activity reported? What are the Sanctions and Penalties for Fraud & Abuse violations? What are the steps in the Fraud & Abuse Investigative Process? What are Providers and Vendors responsibilities? 2

4 It is the policy of PerformCare Introduction To review and investigate all allegations of fraud and/or abuse, whether internal or external; To take corrective actions for any supported allegations after a thorough investigation; and To report confirmed misconduct to the appropriate parties and/or agencies. 3

5 An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to him/herself or some other person. It includes any act that constitutes fraud under applicable federal or state law. What is Fraud? 4

6 What is Abuse? Provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to Health programs, or in reimbursement for services that are not medically necessary or fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Health program. 5

7 What is 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. 6

8 Falsifying Claims/Encounters Incorrect Coding Inappropriate Balance Billing Duplicate Billing Billing for Services Not Rendered Misrepresentation of Services Diagnosis Does Not Correspond to Treatment Rendered Unbundling (billing separately for services that would ordinarily be all inclusive) Coding a service at a higher level than what was rendered (e.g. up coding) Examples of Potential FWA 7

9 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 The acceptance of, or failure to return, monies allowed or paid on claims known to be false or fraudulent documentation Examples of Potential FWA 8

10 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 9

11 Pertinent Laws and Regulations False Claims Act (FCA) Stark Law Anti-Kickback Statute HIPAA Deficit Reduction Act The False Claims Whistleblower Employee Protection Act 10

12 False Claims Act (FCA) The Federal False Claims Act (FCA), 31 U.S.C , creates liability for the submission of a claim for payment to the government that is known to be false in whole or in part. A claim is broadly defined to include any submission that results or could result, in payment. Claims submitted to the government includes claims submitted to intermediaries such as state agencies, managed care organizations and other subcontractors under contract with the government to administer healthcare benefits. Liability can also be created by the improper retention of an overpayment. Penalties can be three times the government s damages plus civil penalties of $5,500 to $11,000 per false claim. 11

13 Stark Law Self-Referral (Stark Law) Statutes, Social Security Act, 1877 Pertains to physician referrals under Medicare and Medicaid. Referrals for the provisions of health care services, if the referring physician or an immediate family member, has a financial relationship with the entity that receives the referral, is not permitted. 12

14 Anti-Kickback Statute 42 U.S. Code It is a criminal offense to knowingly and willfully offer, pay, solicit or receive any remuneration for any item or service that is reimbursable by any federal healthcare program. Penalties many include exclusion from federal health care programs, criminal penalties, jail and civil penalties for each violation. 13

15 Anti-Kickback Statute The Anti-Kickback Law makes it a crime for individuals or entities to knowingly and willfully offer, pay, solicit or receive something of value to induce or reward referrals of business under Federal Healthcare Programs. The Anti-Kickback Law is intended to ensure that referrals for healthcare services are based on medical need and not based on financial or other types of incentives to individuals or groups. 14

16 Anti-Kickback Statute Examples Money Discounts Gratuities Gifts Credits Commissions 15

17 Anti-Kickback Statute In addition to criminal penalties, violation of the Federal Anti-Kickback Statute could result in civil monetary penalties and exclusion from Federal Healthcare Programs, including Medicare and Medicaid Programs. 16

18 HIPPA The Health Insurance Portability and Accountability Act (HIPAA), 45 CFR, Title II, , provides clear definition for Fraud & Abuse control programs, establishment of criminal and civil penalties and sanctions for noncompliance. 17

19 Designed to restrain Federal spending while maintaining the commitment to the federal program beneficiaries. The Deficit Reduction Act (DRA), Public Law No , 6032 Requires compliance for continued participation in the programs. Development of policies and education relating to false claims, whistleblower protections and procedures for detecting and preventing fraud & abuse must be implemented. 18

20 Whistleblower Employee Protection Act 31 U.S.C. 3730(h) - A company is prohibited from discharging, demoting, suspending, threatening, harassing or discriminating against any employee because of lawful acts done by the employee on behalf of the employer or because the employee testifies or assists in an investigation of the employer. 19

21 Whistleblower and Whistleblower Protections: The False Claims Act and some state false claims laws permit private citizens with knowledge of fraud against the U. S. Government or State Government, to file suit on behalf of the government against the person or business that committed the fraud. Individuals who file such suits are known as whistleblowers. The Federal False Claims Act and some State False Claims Acts prohibit retaliation against individuals for investigating, filing or participating in a whistleblower action. 20

22 Patient Protection and Affordable Care Act (PPACA Healthcare Reform Act) 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. 21

23 Criminal Penalties 42 U.S.C. 1128B, 1320a-7b - States that criminal penalties will result in conviction of a felony and a fine of not more than $25,000 and/or imprisonment for not more than 5 years if false statements are knowingly and willfully made for benefits or payments, or misrepresents services or fees to beneficiaries of federal health care programs. 22

24 Administrative Remedies for False Claims 31 U.S.C. Chapter 8, 3801 Any person who makes, presents or submits a claim that is false or fraudulent is subject to a civil penalty of not more than $5,000 for each claim and also an assessment of not more than twice the amount of the claim. 23

25 State Regulations PA Code Chapter 55 Part III. Medical Assistance Manual General Regulations ap1101toc.html Payment Regulations ap1150toc.html MA Bulletins ex.htm 24

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

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

28 Provider Responsibilities Outline of Provider Responsibilities PA Code Provider Manuals (Roles & Responsibilities as Participating Providers) Specific FWA Provider Responsibilities Medically Necessary Services Minimum Documentation Requirements Compliance Program Includes self-disclosure requirements 27

29 Provider Responsibilities PA Code Provider Responsibilities html Medically Necessary Services a.html Provider Prohibited Acts html 28

30 Provider Responsibilities Provider Manuals PerformCare = Section VI: Provider Responsibilities PA PROMISe Provider Handbooks iseproviderhandbooksandbillingguides/index.htm 29

31 Medically Necessary Services a. Clarification regarding the definition of medically necessary statement of policy. Provider Responsibilities 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. 30

32 Minimum Documentation Requirements Chapter (e): Provider Responsibilities 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. 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. 31

33 Provider Responsibilities 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? 32

34 Seven Basic Elements of a Compliance Program as Adopted by OIG and CMS (Under PA HealthChoices, all MCOs and providers are required to have compliance programs) Compliance Plan 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 33

35 Compliance Program New 8th Element 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? 34

36 Self-Audit and Disclosure DHS recommends that providers conduct periodic audits to identify instances where services reimbursed by the MA Program are not in compliance with Program requirements. Internal Monitoring and Auditing Benefits Good faith disclosures and cooperation 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 potential for investigations 35

37 Self Audits DPW Self- Audit and Disclosure Process: Outlined specific procedures to follow on the following webpage: use/medicalassistanceproviderselfauditprotocol/s_ DHS requires providers to return overpayments within 60 days of identifying overpayments For PA HC PSR, providers should conduct selfaudits and return overpayments to BH-MCO (PerformCare) Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered 36

38 Prevention, Detection & Investigation 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) Types of Audits Medicaid Integrity Program (MIP) Medicaid Integrity Group (MIG) Medicaid Integrity Contractors (MIC) 37

39 Prevention, Detection & Investigation State PA Department of State PA Department of Insurance (DOI) PA Attorney General s Office (AG) Medicaid Fraud Control Unit PA Department of Human Services (DHS) Bureau of Program Integrity (BPI) Office of Mental Health and Substance Abuse (OMHSAS) Types of Audits 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 38

40 PerformCare SIU Audits Routine Audits Purpose Scheduled or standard data validation audits, and claims sampling, of contracted providers to ensure compliance with documentation, laws, regulations and billing requirements Monitor providers for possible fraud and abuse. Control assessments, compliance programs, and policies and procedures will be monitored and analyzed for inconsistencies, risk, etc. 39

41 PerformCare SIU Audits Minimum Documentation Requirements for Payment All encounters must have a treatment/service plan, encounter form, and progress notes All must meet the Minimum Documentation Requirements to receive payment from PerformCare 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 40

42 PerformCare SIU 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 41

43 Audit Exceptions 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 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 42

44 Audit Exceptions 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 43

45 Clinical Exceptions 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 44

46 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 45

47 SIU Investigative Process Initial identification of potential fraud through: Retrospective Claims reviews Internal Requests for Review Service Calls/Inquiries from Members, Vendors and/ or Providers Reports from Members, Providers, Clients or other sources (i.e., billing staff, etc.) Data Mining Hotline Calls 46

48 SIU Investigative Process Initial review Evaluation of complaint Evaluation of all supporting documentation Review historical data for any previous referrals with similar reasons/patterns Review case with all appropriate internal resources Decide on action o No evidence of fraud or abuse: Findings are documented and results reported back to the referral source o Potential fraud and/or abuse: SIU will open a case 47

49 SIU Investigative Process Investigation Gather pertinent documents Run Data query for all claims in designated time period Random Sample of member claims requested Review documentation. Involve other Departments as necessary Case Findings and Action Plan established 48

50 SIU Investigative Process Action Plan (may include any or all) Pursue recovery of overpayments Require Corrective Action Plan (CAP) Review for credentialing issues Possible referral to State or Federal Partners Monitoring Program (6 or 12 months) Provider Education 49

51 SIU Investigative Process Noncompliance with Claims Audit (may include any or all) Reversal of Claims Prepayment Review Review for Dis-Enrollment and Suspension of Referrals Referral to State Medicaid Agency Provider and/or Member flags for Monitoring Claims Activities 50

52 Provider Correspondence Initial Request Letter Notification (30 Days) List of members records requested Date records are due Investigator s name and address for mailing 2nd Request Letter for Records (If Necessary, 15 Days) 1st request letter included Date extension for record receipt Consequences for non-compliance Findings Letter Date for receipt of overpayment payment Detailed spreadsheet with overpayment issues outlined Corrective Action Plan and due date Provider Education to be done by Provider Relations If Applicable Payment Arrangement Letter Arrangements for provider payment Signature required 51

53 Goal: Eliminate Improper Payment Resulting from FWA To eliminate FWA successfully providers must work together with PerformCare to prevent and identify inappropriate and potentially fraudulent practices. This can be accomplished by: Monitoring claims submitted for compliance with billing and coding guidelines; Adherence to Treatment Record Standards; Education of all staff members responsible for medical records (billing, coding, maintenance); and Referring cases of suspected FWA 52

54 All together, as providers, BHMCOs, OMHSAS, and BPI, we can help to reduce FWA to decrease wasteful spending in our system. Collaboration = 53

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