Division of Medical Assistance Program Integrity Unit
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1 Division of Medical Assistance Program Integrity Unit
2 Program Integrity Unit Federally mandated Prevent, identify, and investigate potential fraud, waste, and abuse within Medicaid Possible fraud is referred to NC Medicaid Investigations Division Ensure Medicaid funds utilized appropriately
3 Program Integrity Unit Implement remedial measures Prepayment review Administrative actions to address aberrancies/overpayments/abuse Request recovery of overpayments Ensure recipients receive quality care and do not abuse their benefits
4 Program Integrity Mission Ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupments, and identifying avenues for cost avoidance.
5 Program Integrity Authority Federal Code of Federal Regulations (Title 42 Public Health) Social Security Act Amendments Affordable Care Act State North Carolina General Statutes Medicaid State Plan North Carolina Administrative Code (NCAC) State Clinical Policies and Bulletin Articles
6 Federal Fraud and Abuse Laws False Claims Act Anti-Kickback Statute Physician Self-Referral Statute Exclusion Statute Civil Monetary Penalties
7 What is Fraud? Fraud : intentional deception or misrepresentation made by a person 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.
8 What is Abuse? Abuse: Provider practices that are inconsistent with sound fiscal, business or medical practice and result in an unnecessary cost to the Medicaid program. It also includes recipient practices that result in unnecessary cost to the Medicaid program
9 Who is DMA Program Integrity? Quality Assurance Special Projects Business Operations Behavioral Health Program Integrity Business Intake Center Provider Medical Home Care Organized into Sections (circles in the diagram) and Interface with other sections (octagons in the diagram) in DMA and DHHS 9
10 PI Investigative Sections Behavioral Health Review Section Provider types include but are not limited to: outpatient behavioral health community support teams enhanced in home services CAP MR/DD Continually work with MCOs to assure PI functions are performed in accordance with state and federal law
11 PI Investigative Sections Provider Medical Review and Pharmacy Provider types: Nursing facilities Physician and physician-type providers Ambulatory surgery centers Hospitals Dialysis facilities Pharmacy Health departments Federally qualified health clinics Rural health clinics Ambulance Laboratory Radiology
12 PI Investigative Sections Home Care Review Section Provider types include, but are not limited to: Home Health and Hospice Dentists Durable Medical Equipment Private Duty Nursing Personal Care Services Independent Practitioners Community Alternatives Program (CAP) for Disabled Adults and for Children HIV Case Management Home Infusion Therapy and Adult Care Homes
13 PI Investigative Section Resources NCTracks and specialized software to detect/verify possible billing anomalies & investigative leads IBM FAMS IBM Identity Insight Truven JSURS NCTracks Advantage Suite Data Warehouse (SAS)
14 PI Contractors Public Consulting Group (PCG) Post payment reviews Health Management Systems (HMS) Post payment reviews RAC Carolinas Center for Medical Excellence (CCME) Prepayment review
15 Other PI Sections Business Intake Center Receives calls and web inquiries of complaints related to Medicaid fraud, waste or abuse Places all relevant information in the PI Case Tracking System, retrieves provider data from NCTracks and also billing data Forwards all relevant information to PI Sections for further review and disposition
16 Other PI Sections Quality Management Services Contains 2 components: Special Projects and Quality Control Special Projects Manages and coordinates the North Carolina federal and state mandated program integrity reviews, i.e. Payment Error Rate Management (PERM), etc.
17 Other PI Sections Quality Assurance Section Develops and implements policies and procedures for recipient fraud and abuse Coordinates recipient fraud investigations with the county departments of social services
18 PI Investigations & Reviews Post Payment Review Onsite announced or unannounced Desk Prepayment Review Remedial measure Provider Self Audits Special Audits Targeted or Routine Reviews
19 PI Referral Sources Complaints Beneficiaries, public, providers Referrals from formal sources Regulatory agencies, DSS, DHHS partners, DMA program consultants, CMS, OSA Data analysis Federally mandated
20 The PI Investigation Onsite: Investigation Notification*, Introductory Letter & Records Request Desk: Medical Records Request Prepayment review = Desk Reviews Confidential Provider Response/Cooperation Prepay: Time Sensitive! Records Review for Each Claim Providers Receive Instructions and PI Contact Information on Records Requests
21 The PI Investigation Investigative Findings No Errors Overpayment Determinations Claim Denial (Prepayment Only) Administrative Sanctions Referrals (such as AGO/MID, Regulatory agencies) All Adverse Actions* Subject to Reconsideration Reviews Providers receive instructions and PI contact information on PI Correspondence
22 The PI Review Tool/Questionnaire Ensure consistency of review Interpretive guidance Based on program requirements Adaptable to automation Review questionnaires may vary by audit, such as OSA, Hospital Inpatient
23 The PI Review Tool/Questionnaire Q1: Services Authorized/Approved in Accordance with Program Requirements How are the services authorized according to the Medicaid/Health Choice coverage policy? MD Order/Prescription Case Manager (CAP) Authorization Prior Approval (for PCS, PA from the IAE) EPSDT Was there an order/approval/authorization in place on the date of service under review?
24 The PI Review Tool/Questionnaire Q2: Documentation Supports Billed Codes/Modifiers/ Claim Details. Reviewers refer to the Medicaid/Health Choice coverage policy to verify Procedure codes & (if applicable) modifiers Whether or not policy requires specific content, forms/formats for documentation Program requirements for billing quantities (such as a unit or a day ) Does the provider s documentation support the billed claim details and reflect the policy instructions/requirements? Date, quantity, MID, location Procedure codes & modifiers Provider used required forms/formats (if applicable)
25 The PI Review Tool/Questionnaire Q3: Licensing/Training/Credentialing Requirements Met Refer to the Medicaid/Health Choice coverage policy to determine: Provider licensing requirements (such as DHSR license for home care agency) Credentialing/Licensing requirements for direct care staff and/or supervisors Program requirements for staff training Program requirements for staff background checks/other verification Does provider s documentation support the provider agency and/or its staff appropriately licensed/qualified/trained/credentialed?
26 The PI Review Tool/Questionnaire Q4: Required/Covered Components of Service Completed/Provided in Accordance with Policy Refer to the Medicaid/Health Choice coverage policy to determine: Required components such as Plans of Care/Service Plans, Supervision, Assessments/Reassessments, Limits, Frequencies, etc. Covered components, which vary by program and may not be provided to all beneficiaries Does provider documentation support that the required or covered components were completed/provided/documented per policy?
27 The PI Review Tool/Questionnaire Q5: Documentation Supports Services Appropriate for Beneficiary Needs Refer to Medicaid/Health Choice policy to determine: Minimum coverage or medical necessity criteria & how determined EPSDT instructions What s covered, non-covered, eligible beneficiaries, settings, etc. What is considered a duplication of services Does provider documentation support: Services billed per orders, authorization, PA? Services provided per Plan of Care/Service or Treatment Plan Services did not appear to exceed needs
28 What Does PI Mean to Providers? Providers may Meet PI Staff in Person during onsite Audits; educational sessions; hearings Receive from PI regarding requests for documentation; notifications of under or overpayments; educational letters Talk with PI Staff on the phone to call in a complaint; discuss an audit; ask a question
29 Questions? 29
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