MEDICARE AND MEDI-CAL INVESTIGATIONSAND COORDINATION OF ENFORCEMENTPROCEEDINGS - RECENT DEVELOPMENTSVince Blackburn       ...
OVERVIEW OF PRESENTATION Overview Medi-Cal     Understanding  the Investigation and      Enforcement Tools of the Medi-...
BACKGROUND: REDUCING HEALTH CARESPENDING VIA FRAUD ENFORCEMENT     Government                                         How ...
DEFINING MEDI/MEDI FRAUD AND ABUSE42 CFR 455.1 (Program Integrity: Medicaid) definitions:   Fraud means an intentional de...
RESPONSIBLE ENTITIES   Medi-Cal      Department of Health Care Services      California Dept of Justice Bureau of Medi-...
MEDI-CAL INVESTIGATIONS    DEPARTMENT OF HEALTH CARE             SERVICES      ENFORCEMENT OVERVIEW
FIRST LINE OF DEFENSE:PROVIDER ENROLLMENT GATEWAY “A complete application package includes the  application, provider agr...
ONSITE WORK: AUDIT “Amounts paid for services provided to Medi-  Cal beneficiaries shall be audited by the  department in...
ONSITE WORK: INFORMAL REVIEW “The department [of Health Care Services] may  make unannounced visits to any applicant or t...
REMEDIAL AND PREVENTATIVE MEASURES:PPM AUDIT “Postservice prepayment audit … is review for  medical necessity and program...
REMEDIAL AND PREVENTATIVE MEASURES:PRIOR AUTHORIZATION“The director, or a carrier acting under regulations adopted by the...
FRAUD CONTROL:CIVIL MONEY PENALTIES A variety of improper billing scenarios may be  grounds for “a civil money penalty of...
FRAUD CONTROL:PROCEDURE CODE LIMITATIONS “The department [of Health Care Services]  may limit, for 18 months or less, the...
FRAUD CONTROL:WITHHOLDING OF FUNDS“Upon receipt of reliable evidence that would be admissible under [Section 11500 et seq...
FRAUD CONTROL:TEMPORARY SUSPENSION“If it is discovered that a provider is under investigation by the department or any st...
FRAUD CONTROL:PERMISSIVE SUSPENSIONS“The director may suspend a provider of service from further participation under the ...
FRAUD CONTROL:MANDATORY SUSPENSIONS“The director shall suspend a provider of service for conviction of any felony or any ...
PROVIDER REMEDIES:MEET AND CONFER“The department shall develop, in consultation with provider representatives … a process...
MEDI-CAL INVESTIGATIONS   THE MEDICAID INTEGRITY AUDIT    INITIATIVE
DEFICIT REDUCTION ACT OF 2005    Section 6034 (42 U.S.C. § 1396u-6): Creation of     Medicaid Integrity Program (MIP)   ...
DEVELOPMENTS: THE MEDICAID INTEGRITYPROGRAM (“MIP”)  1st federal attempt to audit Medicaid   programs based on suspected ...
TYPES OF MEDICARE INTEGRITY CONTRACTORS(MIC’S)   Education MICs       responsible for educating providers, beneficiaries...
MIC AUDIT PROCESS   Focus: responsibility for monitoring and compliance with    contract provisions relating to fraud and...
THE MEDICARE-MEDICAID DATA MATCHPROGRAM (“THE MEDI-MEDI PROJECT”)   CMS partnership with the State of California to impro...
MEDICARE INVESTIGATIONSMAC‟sZPIC‟sRAC‟s
MEDICARE ADMINISTRATIVECONTRACTORS (MAC) Responsible for ensuring payment of correct  amounts for covered and correctly c...
MAC’S, CONTINUED MAC is required to review Medicare claims in  the course of processing contractor and to  analyze claims...
MEDICARE INTEGRITY PROGRAM (MIP)   Focus:     Detectand prevent fraud in FFS, Medicare      Advantage and Part D program...
THE ZONE PROGRAM INTEGRITY CONTRACTOR(ZPIC) AUDIT INITIATIVE   Focus:       Identify cases of potential fraud, waste, an...
ZPIC ANTI-FRAUD PROCESS   Identify program vulnerabilities   Proactively identify incidents of potential fraud that exis...
ZPIC MODEL   Replacement of program safeguard contractors    (PSC‟s) with seven zone program integrity    contractors (ZP...
TYPES OF COMPLAINTS REFERRED TOPSCS/ZPICS Incorrect reporting of diagnoses or procedures  to maximize payments (Upcoding)...
ZPIC FOCUS   Soliciting, offering, or receiving g, g, g a kickback, bribe, or rebate   Unbundling or “exploding” charges...
THE RECOVERY AUDIT CONTRACTOR (RAC)AUDIT INITIATIVE   3-year RAC Demonstration Project (CA, NY and FL, 2005-    2008) ret...
RAC OVERVIEW   RACs seek to identify improper payments resulting from       Incorrect payments;       non-covered servi...
RAC MODIFICATION FROM DEMONSTRATIONPROGRAM TO PERMANENT PROGRAM                             ReviewerLook-Back Period      ...
RAC FOCUS California: HealthDataInsights, Inc. (HDI),  Recovery Audit Contractor Region D List of specific new issues ap...
PPACA: RELEVANT DEVELOPMENTS   Increased Grounds for Exclusion/Suspension/CMP‟s   Increased funding for health care frau...
PPACA: NEW DATA COLLECTION/SHARING CMS required to integrate data repository to  include claims from all programs, includ...
CMS PROPOSED RULE CMS-6028-P (9.23.10)   Medicare, Medicaid, and CHIP; Additional Screening Requirements,    Application ...
NEW CMS CENTER FOR PROGRAM INTEGRITY(CPI) (SEPT. 2010)   Newly created to serve as CMS focal point for all national and S...
TRENDS IN FRAUD PREVENTION Tighter enrollment review Increased education of providers and  beneficiaries; Early detecti...
GAO IDENTIFIED PRIORITIES/STRATEGY FOR    COMBATTING MEDI/MEDI FRAUD (JUNE 2010)  1. Strengthening provider enrollment pr...
TRENDS: DATA MINING CAPACITY   Increasingly robust capacity to analyze and leverage    data internally and across program...
TRENDS: DATA REVIEW Encounter data use to detect fraud and  abuse. Data Pattern detection:     Service provider and rec...
TRENDS: JOINT INVESTIGATIONS   DRA (2005) included funds for Medi-Medi coordination in    detecting improper billing and ...
CONCLUDING THOUGHTS   Increasing levels of     funding for Medi/Medi fraud enforcement     scrutiny of enrollment appli...
QUESTIONS   Vince Blackburn –       vince.blackburn@dhcs.ca.gov   Harry Nelson –      harry@fentonnelson.com
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Medicare And Medi Cal Investigations And Coordination Lacba Presentation

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Medicare And Medi Cal Investigations And Coordination Lacba Presentation

  1. 1. MEDICARE AND MEDI-CAL INVESTIGATIONSAND COORDINATION OF ENFORCEMENTPROCEEDINGS - RECENT DEVELOPMENTSVince Blackburn Harry NelsonSenior Counsel Fenton Nelson, LLPOffice of Legal ServicesCalifornia Department of Healthcare Services
  2. 2. OVERVIEW OF PRESENTATION Overview Medi-Cal  Understanding the Investigation and Enforcement Tools of the Medi-Cal Program  Medicaid Integrity Contractor Audits Medicare  MAC‟s  ZPIC‟S  RAC‟s Latest Developments/Trends
  3. 3. BACKGROUND: REDUCING HEALTH CARESPENDING VIA FRAUD ENFORCEMENT Government How much Medi/Medi spending is fraud financial obligations or waste? (2020 CBO est. $1t Medicare/$458b Medicaid; +7%yr) (Est. 3-10%)"Medicare has at least $80 billion worth of fraud a year. Thats a full 20percent of every dollar thats spent on Medicare goes to fraud.“—Sen.Tom Coburn“It is not possible to measure precisely the extent of fraud in Medicareand Medicaid.“-- Daniel Levinson, HHS Inspector General
  4. 4. DEFINING MEDI/MEDI FRAUD AND ABUSE42 CFR 455.1 (Program Integrity: Medicaid) definitions: Fraud means an 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 related to Medicaid. Abuse means provider practices that are inconsistent with sound fiscal, business, or medical practices, and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary of that fail to meet professional recognized standards for health care. It also includes recipient practices that result in unnecessary costs to the Medicaid
  5. 5. RESPONSIBLE ENTITIES Medi-Cal  Department of Health Care Services  California Dept of Justice Bureau of Medi-Cal Fraud and Elder Abuse (California‟s Medicare Fraud Control Unit (MFCU)  Medicaid Integrity Program Contractor (MIP, MIC) Medicare  DOJ/FBI/HHS-OIG  Medicare Administrative Contractor (MAC)  Recovery Audit Contractor (RAC)  Medicare Secondary Payor RAC (MSP RAC)  Zone Program Integrity Contractor (ZPIC) (formerly Program Safeguard Contractor (PSC))  Qualified Independent Contractor (QIC)For full contractors list, see http://www2.cms.gov/ Medicare ContractingReform/Downloads /FunctionalEnvironment.pdf
  6. 6. MEDI-CAL INVESTIGATIONS DEPARTMENT OF HEALTH CARE SERVICES ENFORCEMENT OVERVIEW
  7. 7. FIRST LINE OF DEFENSE:PROVIDER ENROLLMENT GATEWAY “A complete application package includes the application, provider agreement, disclosure statement and all required attachments … .”Directions on medi-cal.ca.gov Provider Enrollment website
  8. 8. ONSITE WORK: AUDIT “Amounts paid for services provided to Medi- Cal beneficiaries shall be audited by the department in the manner and form prescribed by the department.” “[C]ost reports and other data … shall be considered true and correct unless audited or reviewed within three years after the close of the period covered by the report … .”Welfare and Institutions Code § 14170
  9. 9. ONSITE WORK: INFORMAL REVIEW “The department [of Health Care Services] may make unannounced visits to any applicant or to any provider for the purpose of determining whether enrollment, continued enrollment, or certification is warranted, or as necessary for the administration of the Medi-Cal program.”Welfare and Institutions Code, § 14043.7(a) “During normal working hours, the department [of Health Care Services] may make any examination of the books and records of, and may visit and inspect the premises or facilities of [providers.]”Welfare and Institutions Code, § 14124.2(a)(1)
  10. 10. REMEDIAL AND PREVENTATIVE MEASURES:PPM AUDIT “Postservice prepayment audit … is review for medical necessity and program coverage after service was rendered but before payment is made. Payment may be withheld or reduced if the service rendered was not a covered benefit, deemed medically unnecessary or inappropriate.”Welfare and Institutions Code, § 14133(b) “Special claims review may be imposed on a provider upon a determination that the provider has submitted improper claims, including claims which incorrectly identify or code services provided.”California Code of Regulations, title 22, § 51460(a)
  11. 11. REMEDIAL AND PREVENTATIVE MEASURES:PRIOR AUTHORIZATION“The director, or a carrier acting under regulations adopted by the director, may require that any individual provider shall receive prior authorization before providing services when the director or carrier determines that the provider has been rendering unnecessary services.”Welfare and Institutions Code, § 14103.6
  12. 12. FRAUD CONTROL:CIVIL MONEY PENALTIES A variety of improper billing scenarios may be grounds for “a civil money penalty of not more than three times the amount claimed for each item or service.”Welfare and Institutions Code, § 14123.2 Improper claims “for a service or item about which the provider has received two or more warning notices of improper billing, [may] subject [the provider] to a civil money penalty of one hundred dollars ($100) per claim, or up to two times the amount improperly claimed for each item or service, whichever is greater.”Welfare and Institutions Code, § 14123.25(c)
  13. 13. FRAUD CONTROL:PROCEDURE CODE LIMITATIONS “The department [of Health Care Services] may limit, for 18 months or less, the [CPT-4, NDC, HCPCS, or HIPAA codes] for which any provider may bill” if: “The department determines, by audit or other investigation, that excessive services or billings, or abuse, has occurred” or “The Medical Board of California or other licensing authority or a court of competent jurisdiction limits a licensees practice of medicine or the rendering of health care.”Welfare and Institutions Code, § 14044(a)
  14. 14. FRAUD CONTROL:WITHHOLDING OF FUNDS“Upon receipt of reliable evidence that would be admissible under [Section 11500 et seq.] of the Government Code, of fraud or willful misrepresentation … the department may … [w]ithhold payment for any goods, services, supplies, or merchandise, or any portion thereof.”Welfare and Institutions Code, § 14107.11
  15. 15. FRAUD CONTROL:TEMPORARY SUSPENSION“If it is discovered that a provider is under investigation by the department or any state, local, or federal government law enforcement agency for fraud or abuse, that provider shall be subject to temporary suspension from the Medi-Cal program.”Welfare and Institutions Code, § 14043.36
  16. 16. FRAUD CONTROL:PERMISSIVE SUSPENSIONS“The director may suspend a provider of service from further participation under the Medi-Cal program for violation of any provision of [Welfare and Institutions Code sections 14000 through 14499.77] or any rule or regulation promulgated by the director [of the Department of Health Care Services] pursuant to those chapters. ”Welfare and Institutions Code, § 14123(a)
  17. 17. FRAUD CONTROL:MANDATORY SUSPENSIONS“The director shall suspend a provider of service for conviction of any felony or any misdemeanor involving fraud, abuse of the Medi-Cal program or any patient, or otherwise substantially related to the qualifications, functions, or duties of a provider of service.”Welfare and Institutions Code, § 14123(a)
  18. 18. PROVIDER REMEDIES:MEET AND CONFER“The department shall develop, in consultation with provider representatives … a process that enables a provider to meet and confer with the appropriate department officials within 30 days after the issuance of a letter notifying the provider of a temporary withhold of payments, pursuant to Section 14107.11, or a temporary suspension, pursuant to subdivision (a) of Section 14043.36, for the purpose of presenting and discussing information and evidence that may impact the departments decision to modify or terminate the sanction.”Welfare and Institutions Code, § 14123.05
  19. 19. MEDI-CAL INVESTIGATIONS THE MEDICAID INTEGRITY AUDIT INITIATIVE
  20. 20. DEFICIT REDUCTION ACT OF 2005  Section 6034 (42 U.S.C. § 1396u-6): Creation of Medicaid Integrity Program (MIP)  Significant Increase of CMS and HHS-OIG Resources to Fight Medicaid Fraud  Funding - $560M over 5 Years  $255m for Medicaid Integrity Program  $180m for National Medi-Medi Expansion  $125m for OIG for Medicaid Fraud  Staffing - 100 FTEs for CMS  First national anti-fraud program for Medicaid 20
  21. 21. DEVELOPMENTS: THE MEDICAID INTEGRITYPROGRAM (“MIP”) 1st federal attempt to audit Medicaid programs based on suspected higher error rates CMS delegated • Division of Medicaid Integrity Contracting (Oversees MIC‟s)responsibility for the MIP 1 to the Medicaid Integrity • Division of Fraud Research and Detection (identifying fraud patterns and trends and reporting to MIC‟sGroup ("MIG"). 2 and states) Office of the Group • Division of Field Operations (SF) • program integrity reviews of theDirector oversees: states 3 • technical assistance/training to states
  22. 22. TYPES OF MEDICARE INTEGRITY CONTRACTORS(MIC’S) Education MICs  responsible for educating providers, beneficiaries, and others on program integrity and quality of care issues  review MICs Review MICs (California (Reg. IX): AdvanceMed)  analyze Medicaid providers„  claims data for evidence of atypical billing practices that could result in overpayments. Audit MICs (California (Reg. IX): Health Management Solutions (HMS)  post-payment audits of Medicaid providers.  leads received from CMS, state agencies, or review of MIC‟s
  23. 23. MIC AUDIT PROCESS Focus: responsibility for monitoring and compliance with contract provisions relating to fraud and abuse prevention and reporting (recipients, providers, representatives) Process:  Identify potential audit targets through data analysis  Vet potential audits with State and law enforcement Assignment to Audit MIC Actions following audit can include:  prepayment review  recommendations for termination  site visits  sanctions
  24. 24. THE MEDICARE-MEDICAID DATA MATCHPROGRAM (“THE MEDI-MEDI PROJECT”) CMS partnership with the State of California to improve coordination of Medicare and Medicaid program integrity efforts. Integrity program launched in California in 2001 to detect and prevent Medicaid fraud and abuse. Expanded to other states after the Deficient Reduction Act of 2005 increased funding to $480 million over a 10-year period for nat‟l roll-out. Objective: match Medicare and Medicaid data to proactively identify program vulnerabilities and potential fraud and abuse that may have gone undetected by reviewing Medicare and Medicaid program data individually.
  25. 25. MEDICARE INVESTIGATIONSMAC‟sZPIC‟sRAC‟s
  26. 26. MEDICARE ADMINISTRATIVECONTRACTORS (MAC) Responsible for ensuring payment of correct amounts for covered and correctly coded services rendered to eligible beneficiaries by legitimate providers Review billing errors California (Reg. IX): Palmetto (Parts A/B); Noridian (DME)
  27. 27. MAC’S, CONTINUED MAC is required to review Medicare claims in the course of processing contractor and to analyze claims data and other information (e.g., complaints) to identify suspected billing problems When MAC verifies that an error exists through a review of a small sample of claims, the contractor classifies the severity of the problem as minor, moderate, or significant and imposes corrective actions, e.g. pre- payment/postpayment review
  28. 28. MEDICARE INTEGRITY PROGRAM (MIP) Focus:  Detectand prevent fraud in FFS, Medicare Advantage and Part D programs;  Ensure integrity of FFS enrollment process;  Promote compliance with Medicare rules. Includes:  PSC‟s  ZPIC‟s  MAC‟s can qualify as ZPIC‟s
  29. 29. THE ZONE PROGRAM INTEGRITY CONTRACTOR(ZPIC) AUDIT INITIATIVE Focus:  Identify cases of potential fraud, waste, and abuse in Medicare, develop them thoroughly and in a timely manner, and take immediate action to ensure that Medicare Trust Fund monies are not inappropriately paid out and that any mistaken payments are recouped.  Impose Administrative Actions Support federal law enforcement in the investigation and prosecution of Medicare fraud casesThe PSCs and the ZPICs function into Seven zones based on MAC jurisdictions; California is one of five “hot spots” (also FL, IL, NY, TX); many states still using PSC‟s
  30. 30. ZPIC ANTI-FRAUD PROCESS Identify program vulnerabilities Proactively identify incidents of potential fraud that exist within its service area and taking appropriate action on each case Pursue leads through data analysis, Internet, the Fraud Investigation Database (FID), news, etc Generate and/or identify leads by internal data (claims processing, data analysis, audit and reimbursement, appeals, medical review, enrollment) Investigate allegations of fraud made by beneficiaries, providers, CMS, OIG, and other sources Initiating appropriate administrative actions to deny or to suspend payments that should not be made to providers where there is reliable evidence of fraud; Refer cases for civil and criminal prosecution and/or application of administrative sanctions Initiate and maintain educational, networking, and outreach activities to ensure effective interaction and exchange of information with internal components as well as outside groups;
  31. 31. ZPIC MODEL Replacement of program safeguard contractors (PSC‟s) with seven zone program integrity contractors (ZPIC‟s). Coordinate benefit integrity activity nationwide - “rapid response teams with a more aggressive fraud fighting mandate”--Kim Brandt, director of the CMS Program Integrity Group. Five of the seven ZPICS will be assigned to “hot spot” areas -California, Florida, New York, Illinois and Texas…. Trend reflected: resolve more fraud and abuse and overpayment matters administratively, including sanctions and education
  32. 32. TYPES OF COMPLAINTS REFERRED TOPSCS/ZPICS Incorrect reporting of diagnoses or procedures to maximize payments (Upcoding) Billing for services not furnished and/or supplies not provided Billing that appears to be a deliberate application for duplicate payment for same services or supplies Misrepresenting as medically necessary, non‐covered services by using inappropriate procedure or diagnosis codes
  33. 33. ZPIC FOCUS Soliciting, offering, or receiving g, g, g a kickback, bribe, or rebate Unbundling or “exploding” charges Completing Certificates of Medical Necessity (CMN) for patients not personally and professionally known by the provider Using an incorrect or inappropriate provider number in order to be paid Participating in schemes involving collusion between a provider and a beneficiary resulting in higher costs or charges to the Program Altering claim forms, electronic claim records, medical documentation, etc., to obtain a higher payment amount Billing based on “gang visits” Misrepresentations Billing non-covered or non-chargeable services as covered items Using another persons Medicare card to obtain medical caream
  34. 34. THE RECOVERY AUDIT CONTRACTOR (RAC)AUDIT INITIATIVE 3-year RAC Demonstration Project (CA, NY and FL, 2005- 2008) returned $992.7m in overpayments to Medicare (net savings $693m) Made permanent by Section 302 of the Tax Relief and Health Care Act of 2006 -- 50 state expansion mandated by 2010 Expanded by PPACA (Medicaid, Part C, D) by 12.31.10 (§ 6411) Focus: to reduce Medicare improper payments through efficient detection and collection of overpayments, identification of underpayments and the implementation of actions that will prevent future improper payments  detect and correct past improper payments so that MACs et al. can implement actions that will prevent future
  35. 35. RAC OVERVIEW RACs seek to identify improper payments resulting from  Incorrect payments;  non-covered services (e.g. no medical necessity)  incorrectly coded services  duplicate services Methods of RAC review:  automated review (claims data without records; based on certainty that overpayment occurred)  Complex review (medical record review based on high probability of overpayment) No random review  RAC‟s charged with “targeted review”: using proprietary “data analysis techniques” to determine claims likely to contain overpayments Medicare Prescription Drug, Improvement, and Modernization Act of 2003, § 935)
  36. 36. RAC MODIFICATION FROM DEMONSTRATIONPROGRAM TO PERMANENT PROGRAM ReviewerLook-Back Period RAC Fees QualificationsDemo: reopen claims Demo: No up to 4 yrs following physician medical Demo: contingent fee the date of initial directors or (avg >14%) based onpayment (criticized as qualification 1st stage appeal violative of SSA requirements for decision, even if later overturned (AMA: “a“provider without fault” reviewers Permanent: bounty hunter-like provisions) Mandatory program”) employment of contractor physician Permanent: RAC getsPermanent: Claims med. directors no contingency fee and (CMD); medical must repay CMS thereopened only up to amount it received Ifthree years following necessity determinations by RN provider appeals anddate of initial payment or therapist; coding prevails at any level. review by certified Fee capped 9-12.5% coders
  37. 37. RAC FOCUS California: HealthDataInsights, Inc. (HDI), Recovery Audit Contractor Region D List of specific new issues approved by CMS for review: http://racinfo.healthdatainsights.com Examples of issues  Pharmacy Supply and Dispensing Fees  Wheelchair Bundling  Untimed Codes
  38. 38. PPACA: RELEVANT DEVELOPMENTS Increased Grounds for Exclusion/Suspension/CMP‟s Increased funding for health care fraud and abuse control programs and enforcement Increased screening/scrutiny of enrollment applications Broadened disclosure requirements, e.g. beginning 3.23.2011, applicants for enrollment or revalidation of enrollment must disclose current or previous affiliations with any provider or supplier who has:  Uncollected debt  Payment suspended  Been Excluded from federal health care programs  Had Billing Privileges Revoked State Medicaid agencies required to terminate participation of any individual or entity if participation in Medicare or any other state‟s Medicaid program te
  39. 39. PPACA: NEW DATA COLLECTION/SHARING CMS required to integrate data repository to include claims from all programs, including Medi-Medi, VA, etc., to match HHS data in fighting Medicare and Medicaid fraud (§ 6402) New national health care fraud and abuse data collection program of certain adverse events (§ 6403) OIG and Attorney General given access to HHS and HHS contractor claims and payment data to conduct law enforcement and oversight activities
  40. 40. CMS PROPOSED RULE CMS-6028-P (9.23.10) Medicare, Medicaid, and CHIP; Additional Screening Requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspensions and Compliance Plans for Providers and Suppliers:  Establishes requirements for suspending payments to providers and suppliers based on credible allegations of Medicare and Medicaid fraud;  Establishes authority for temporary moratoria on enrollment on providers and suppliers when necessary to help prevent or fight fraud, waste, and abuse without impeding beneficiaries‟ access to care.  Strengthens provider enrollment and screening procedures to more accurately assure that fraudulent providers are not gaming the system and that only qualified providers/suppliers are allowed to enroll/bill;  Outlines req‟t for states to terminate providers from Medicaid/CHIP when terminated by Medicare, other state Medicaid /CHIP;  Solicits input on how to best structure and develop mandatory
  41. 41. NEW CMS CENTER FOR PROGRAM INTEGRITY(CPI) (SEPT. 2010) Newly created to serve as CMS focal point for all national and State-wide Medicare and Medicaid programs and CHIP integrity fraud and abuse issues. Focus  Promoting integrity of the Medicare and Medicaid programs and CHIP through provider/contractor audits and policy reviews, identification and monitoring of program vulnerabilities, and providing support and assistance to States. Recommends modifications to programs and operations as necessary and works with CMS Centers, Offices, and the Chief Operating Officer (COO) to affect changes as appropriate.  Collaborate with the Office of Legislation on the development and advancement of new legislative initiatives and improvements to deter, reduce, and eliminate fraud, waste and abuse.  Oversees all CMS interactions and collaboration with key stakeholders relating to program integrity (i.e., U.S. Department of Justice, DHHS Office of Inspector General, State law enforcement agencies, other Federal entities, CMS components) for the purposes of detecting, deterring, monitoring and combating fraud and abuse, as well as taking action against those that commit or participate in fraudulent or other unlawful activities.  Develop and implement a comprehensive strategic plan, objectives and measures to carry out CMS Medicare, Medicaid and CHIP program integrity mission and goals, and ensure program vulnerabilities are identified and resolved.
  42. 42. TRENDS IN FRAUD PREVENTION Tighter enrollment review Increased education of providers and beneficiaries; Early detection (medical review, data analysis) Enhanced data collection and information sharing Increased coordination between agencies, contractors, and law enforcement
  43. 43. GAO IDENTIFIED PRIORITIES/STRATEGY FOR COMBATTING MEDI/MEDI FRAUD (JUNE 2010) 1. Strengthening provider enrollment process and standards.  Provider background checks pre-enrollmt - identify bad actors, esp. vulnerable areas 2. Improving pre-payment review of claims.  ensure that Medicare pays correctly the the outset via additional automated pre- payment claim review 3. Focusing post-payment claims review on most vulnerable areas.  More post- payment reviews identify payment errors and recoup overpayments.  More targeting of most vulnerable areas. 4. Improving oversight of contractors.  Expanded oversight of contractors‟ activities to address fraud, waste, and abuse  Criticized CMS oversight of prescription drug plan sponsors‟ compliance programs 5. Developing a robust process for addressing identified vulnerabilities.  Insufficient CMS process to ensure prompt resolution of identified vulnerabilities  Need for new mechanisms in place to resolve emerging improper payment areasTestimony of GAO Director of Healthcare Kathleen King
  44. 44. TRENDS: DATA MINING CAPACITY Increasingly robust capacity to analyze and leverage data internally and across programs/contractors Provider data-analysis tools and data-analysis methods for Medicare and Medicaid fraud and-abuse detection  CMS‟s One PI (One Program Integrity System Integrator) - Medi-Medi integration: perceived success  MMIS (Medicaid Management Information System) – master claims database  regional office reviews subset of the MMIS database, reviews to identify algorithms, identifies potential Medicaid claims problems, pulls the provider number, notifies state
  45. 45. TRENDS: DATA REVIEW Encounter data use to detect fraud and abuse. Data Pattern detection:  Service provider and recipient identifiers  Procedure codes  Product and service descriptions  Provider payment Data Mapping: identify referral relationships (Stark/AKS Tool)
  46. 46. TRENDS: JOINT INVESTIGATIONS DRA (2005) included funds for Medi-Medi coordination in detecting improper billing and utilization patterns by matching Medicare and Medicaid claims information on providers and beneficiaries to reduce fraudulent schemes that cross program boundaries.  Also: coordination of actions by CMS, State agencies, the Attorney General, and the HHS OIG to protect Medicaid and Medicare expenditures HHS/DOJ Health Care Fraud Prevention and Enforcement (HEAT) (2009)  Cabinet-level joint task force consisting of senior level leadership from both departments under leadership of HHS Secretary Sebelius and Attorney General  Took over Medicare Strike Force teams--inaugurated in Miami (2007) ” now teams in Los Angeles, Houston, Detroit, Brooklyn, Tampa and Baton Rouge  500+ health care fraud criminal indictments to date
  47. 47. CONCLUDING THOUGHTS Increasing levels of  funding for Medi/Medi fraud enforcement  scrutiny of enrollment applications, claims data  data sharing  inter-agency coordination (Medi-Medi and enforcement-oversight) and collaboration Increasing risk of sanctions Increasing overlap (decreasing demarcation) between federal and state responsibilities
  48. 48. QUESTIONS Vince Blackburn – vince.blackburn@dhcs.ca.gov Harry Nelson – harry@fentonnelson.com

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