Provider Training Series
The Search for Compliance
Annual Mandatory Training for all Providers
Annual Training for All
Providers
Compliance with Medicaid
Detection and Prevention of Fraud, Waste, and
Abuse
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
Compliance:
Fraud, Waste, and Abuse
(FWA)
Fraud, Waste, and Abuse
1.
Definitions
2.
Types of Fraud
3.
FWA Trends in Behavioral Health and Medicaid
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.
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
FWA Definitions
WASTE
•
Thoughtless or careless expenditure, consumption,
mismanagement, use or squandering of healthcare
resources, including incurring costs because of
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
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
Types of Fraud
Abuse of Recipients
• Physical, mental, emotional or sexual abuse
• Discrimination
• Neglect
Types of Fraud
Denial of Medically Necessary Services
• Denying access to services
• Limiting access to services
• Failure to refer to needed specialist
Types of Fraud
Overutilization of Services
• Providing unnecessary services
• Unbundling multiple services
• Overlapping services
• Billing for excessive units
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
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
Collaboration =
“All together, as providers,
BH-MCOs, OMHSAS, and BPI, we
can help to reduce FWA to
decrease wasteful spending in
our system.”
Overview of Regulations
1.
Federal Regulations
2.
State Regulations
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
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
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
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.
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.
State Regulations
PA Code
•
Chapter 55 Part III. Medical Assistance Manual
– http://www.pacode.com/secure/data/055/partIIItoc.html
•
General Regulations
– http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html•
Payment Regulations
– http://www.pacode.com/secure/data/055/chapter1150/chap1150toc.html•
MA Bulletins
– http://www.dpw.state.pa.us/publications/bulletinsearch/index.htmState Regulations
PA PROMISe
•
PA PROMISe Provider Handbooks
– http://www.dpw.state.pa.us/publications/forproviders/promiseproviderhandb ooksandbillingguides/index.htm
•
Mental Health Requirements
– http://www.dpw.state.pa.us/provider/mentalhealth/index.htm
•
PA Recovery (for information by level of care)
State Regulations
PA HealthChoices
•
HealthChoices Behavioral Health Publications
– http://www.dpw.state.pa.us/publications/healthchoicesbehavioralhea lthpublications/index.htm
VBH-PA Contract Requirements
VBH-PA Provider Manual
•
http://www.vbh-pa.com/provider/info/prvmanual/toc.htm
•
Fraud and abuse webpage from provider manual
-
http://www.vbh-pa.com/provider/info/prvmanual/6_ClmsPyt/fraud_a
buse.htm
VBH-PA Contract Requirements
Provider Notifications
•
Provider Online Services
– http://www.vbh‐pa.com/providers.htm
•
ValueAdded
– http://www.vbh‐pa.com/provider/value_added_newsletter_archive.htm•
Mandatory Trainings
– http://www.vbh‐pa.com/fraud_abuse.htm – http://www.vbh‐pa.com/provider/prv_trn.htm•
Provider Alerts
Federal Compliance
Program Requirements
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
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?
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
Provider Responsibilities
1.
Outline of Provider Responsibilities
–
PA Code
–
Provider Manuals
2.
Specific FWA Provider Responsibilities
–
Medically Necessary Services
–
Minimum Documentation Requirements
–
Compliance Program
Outline: Provider Responsibilities
PA Code
•
Provider Responsibilities 1101
– http://www.pacode.com/secure/data/055/chapter1101/s1101.51.html
•
Medically Necessary Services 1101
– http://www.pacode.com/secure/data/055/chapter1101/s1101.21a.html
•
Provider Prohibited Acts 1101
Outline: Provider Responsibilities
Provider Manuals
•
VBH-PA = Section IV: Participating Provider
Responsibilities
– http://www.vbh‐pa.com/provider/info/prvmanual/toc.htm
•
PA PROMISe Provider Handbooks
– http://www.dpw.state.pa.us/publications/forproviders/promiseproviderhandb ooksandbillingguides/index.htm
Specific FWA Provider
Responsibilities
Medically Necessary Services
§ 1101.21a. 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.
Specific FWA Provider
Responsibilities
Minimum Documentation Requirements
Chapter 1101.51 (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.”
Specific FWA Provider
Responsibilities
Minimum Documentation Requirements
Chapter 1101.51 (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
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?
Specific FWA Provider
Responsibilities
Minimum Documentation Requirements
•
VBH-PA Minimum Documentation Requirements
–http://www.vbh-pa.com/fraud/pdfs/Minimum-Provider-Documentation-Standards-for-Payment.pdf
•
Other Treatment Record Requirements
– VBH-PA Provider Online Services• http://www.vbh-pa.com/providers.htm
– MA Bulletin 19-97-10
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
self-audits 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.”
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.”
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
Specific FWA Provider
Responsibilities
DPW Self- Audit and Disclosure Process:
•
Outlined specific procedures to follow on the following
webpage:
– http://www.dpw.state.pa.us/learnaboutdpw/fraudandabuse/medicalassist anceproviderselfauditprotocol/S_001151
•
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
Specific FWA
Provider
Responsibilities
VBH-PA Self- Audit
and Disclosure Process:
– http://www.vbh‐
pa.com/fraud/pdfs/Provider_Self_ Audit_Referral_Form.pdf
Medicaid and BH-MCO
Prevention and Detection
Prevention and Detection
1.
Enforcement Agencies
2.
Types of Audits
3.
VBH-PA Audits
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)
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)Types of Audits
Federal
• Medicaid Integrity Program (MIP)
• Medicaid Integrity Group (MIG)
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.
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
– http://www.vbh-pa.com/fraud/pdfs/Audit_Process.pdfVBH-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)
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
VBH-PA Program Integrity Audits
Minimum Documentation
Requirements for Payment
•
http://www.vbh-pa.com/fraud/pdfs/Minimum-
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
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
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
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
VBH-PA Program Integrity Audits
Audit Exceptions
http://www.vbh-pa.com/fraud/pdfs/Program-Integrity-Exceptions-and-Findings.pdf
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
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
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
