HFMAHFMA REGION 2 ANNUAL REGION 2 ANNUAL FALL INSTITUTE: OMIG FALL INSTITUTE: OMIG DEVELOPMENTS-2010 DEVELOPMENTS-2010

JAMES G. SHEEHANJAMES G. SHEEHANMEDICAID INSPECTOR GENERALMEDICAID INSPECTOR GENERAL

518 473-3782518 473-3782James.Sheehan@omig.ny.govJames.Sheehan@omig.ny.gov

WWW.OMIG.NY.GOVWWW.OMIG.NY.GOV

2011-12 WILL BE THE MOST 2011-12 WILL BE THE MOST DIFFICULT BUDGET YEAR FOR DIFFICULT BUDGET YEAR FOR NEW YORK AND OMIGNEW YORK AND OMIG

• Administration must address budget, cash, and taxpayer Administration must address budget, cash, and taxpayer accountability issues “eliminating wasteful spending, accountability issues “eliminating wasteful spending, and fighting fraud and abuse.”and fighting fraud and abuse.”

• State departments, school districts, health care State departments, school districts, health care providers, state parks, have all taken cuts-and will providers, state parks, have all taken cuts-and will undoubtedly take more.undoubtedly take more.

• Enrollment in Medicaid has risen substantially as result Enrollment in Medicaid has risen substantially as result of recession.of recession.

• Increase in budget expectation for OMIG-recoveries and Increase in budget expectation for OMIG-recoveries and savings of $1.2 billion for FY 2010-2011 (more than savings of $1.2 billion for FY 2010-2011 (more than double level in 2008-2009)NOTE: includes substantial double level in 2008-2009)NOTE: includes substantial third party cost avoidance.third party cost avoidance.

• High expectations and support for OMIG mission - High expectations and support for OMIG mission - Governor, Legislature, public, CMS.Governor, Legislature, public, CMS.

• Significant changes in law under Affordable Care Act.Significant changes in law under Affordable Care Act.

OMIG CHALLENGESOMIG CHALLENGES

• Budget, program integrity, and compliance Budget, program integrity, and compliance objectives for OMIG:objectives for OMIG:– are improper payments being identified, reported, and are improper payments being identified, reported, and

recovered? recovered? – What are we doing to prevent improper payments? What are we doing to prevent improper payments? – How are we recovering improper payments? How are we recovering improper payments?

• Fairness and transparency- the basis for and the Fairness and transparency- the basis for and the process for OMIG actions. How can health process for OMIG actions. How can health providers understand and plan for OMIG audits, providers understand and plan for OMIG audits, reviews, matches of their activities?reviews, matches of their activities?

• Compliance mandates-every provider must have Compliance mandates-every provider must have “effective” compliance program, including “effective” compliance program, including reporting of overpayments.reporting of overpayments.

OMIG CHALLENGESOMIG CHALLENGES

• LEGISLATIVE CONCERNS:LEGISLATIVE CONCERNS:– REPUBLICAN TASK FORCE STATEMENT, JANUARY REPUBLICAN TASK FORCE STATEMENT, JANUARY

2010-OMIG NEEDS TO INCREASE RECOVERIES 2010-OMIG NEEDS TO INCREASE RECOVERIES FROM FRAUD, WASTE, AND ABUSE. “It’s time for a FROM FRAUD, WASTE, AND ABUSE. “It’s time for a bare-knuckles effort to repossess the potentially bare-knuckles effort to repossess the potentially billions of state dollars being lost to abuse, fraud, billions of state dollars being lost to abuse, fraud, and waste,” Senator George Winner, Elmira.  and waste,” Senator George Winner, Elmira. 

– SENATOR Craig Johnson, Glen Cove - Proposes SENATOR Craig Johnson, Glen Cove - Proposes Legislative Commission on Medicaid Fraud Waste Legislative Commission on Medicaid Fraud Waste and Abuse “to review operations of OMIG.” and Abuse “to review operations of OMIG.”

– Assembly bills on audit sampling and projection.Assembly bills on audit sampling and projection.

OMIG CHALLENGESOMIG CHALLENGES

• OUTSIDE PERCEPTIONS OF NEW YORK MEDICAID OUTSIDE PERCEPTIONS OF NEW YORK MEDICAID HAVE TRAILED THE FACTS:HAVE TRAILED THE FACTS:– ““You know, there are estimates that there’s $15 billion You know, there are estimates that there’s $15 billion

worth of fraud in Medicaid a year in New York City alone.” worth of fraud in Medicaid a year in New York City alone.” Senator Tom Coburn at yesterday’s Obama Health SummitSenator Tom Coburn at yesterday’s Obama Health Summit

– FACT: Actual CMS estimate: 1.5% improper payments to FACT: Actual CMS estimate: 1.5% improper payments to New York Medicaid providers in 2008.(Payment Error Rate New York Medicaid providers in 2008.(Payment Error Rate Measurement program “PERM”)Measurement program “PERM”)

– ““The biggest thing on fraud is to have undercover patients The biggest thing on fraud is to have undercover patients so that people know we’re checking on whether or not this so that people know we’re checking on whether or not this is a legitimate bill.” Senator Tom Coburn at Obama Health is a legitimate bill.” Senator Tom Coburn at Obama Health SummitSummit

– FACT: New York has used investigators posing as FACT: New York has used investigators posing as undercover patients since at least the 1990’sundercover patients since at least the 1990’s

WHY CAN’T WE GO BACK TO WHY CAN’T WE GO BACK TO THE GOOD OLD DAYS BEFORE THE GOOD OLD DAYS BEFORE OMIG?OMIG?

• ““In an audit released last month, the (HHS) In an audit released last month, the (HHS) inspector general revealed that in New York City inspector general revealed that in New York City schools, 86 percent of the Medicaid claims that schools, 86 percent of the Medicaid claims that were paid from 1993 to 2001 lacked were paid from 1993 to 2001 lacked anyany explanationexplanation for why the services had been for why the services had been ordered... In Buffalo and other upstate schools, the ordered... In Buffalo and other upstate schools, the auditors concluded that the figure was 56 percent auditors concluded that the figure was 56 percent for the same periodfor the same period.”*.”*

*- Source: New York Times article 2005

WHY DID THE LEGISLATURE WHY DID THE LEGISLATURE CREATE OMIG? CREATE OMIG?

• 2005 New York Times Series2005 New York Times Series

• ““The investigation found audits on Medicaid spending that The investigation found audits on Medicaid spending that were brushed aside, and reports on waste that appear to have were brushed aside, and reports on waste that appear to have been shelved.” been shelved.”

• According to the Times, when “asked repeatedly to provide an According to the Times, when “asked repeatedly to provide an in-depth explanation of their claim of major savings or for any in-depth explanation of their claim of major savings or for any state records or other documentation to back up the figures, state records or other documentation to back up the figures, department officials would not supply any.”department officials would not supply any.”

• Fraud and abuse recoveries as percentage of Medicaid budget-Fraud and abuse recoveries as percentage of Medicaid budget-– 2000=.5 %2000=.5 %– 2003=.3%2003=.3%– 2004 <.2% (all as calculated by New York Times)2004 <.2% (all as calculated by New York Times)

WHY DID THE LEGISLATURE WHY DID THE LEGISLATURE CREATE OMIG?CREATE OMIG?• CONSEQUENCES OF OLD MODEL:CONSEQUENCES OF OLD MODEL:

Spotlight by the Federal Government-2006 REPORTSpotlight by the Federal Government-2006 REPORT

• ““As the largest single Medicaid program in the nation, New As the largest single Medicaid program in the nation, New York’s anti-fraud efforts over the last several years have not York’s anti-fraud efforts over the last several years have not been proportionate to its vulnerability.”been proportionate to its vulnerability.”

• ““New York must do more to meet its program integrity New York must do more to meet its program integrity obligations.” obligations.”

• ““The Health Department's shift away from enforcing Medicaid The Health Department's shift away from enforcing Medicaid antifraud rules and toward greater emphasis on educating antifraud rules and toward greater emphasis on educating providers on how to do things right [was] a shift it found providers on how to do things right [was] a shift it found troubling.” (New York Times summary)troubling.” (New York Times summary)

OMIG – A Legislative Solution OMIG – A Legislative Solution to Address Identified Issuesto Address Identified Issues

• After a Joint, Bi-Partisan Legislative Conference Committee, in July 2006 After a Joint, Bi-Partisan Legislative Conference Committee, in July 2006 Office of Medicaid Inspector General created as an independent entity Office of Medicaid Inspector General created as an independent entity separate from Department of Health. New law took effect in November separate from Department of Health. New law took effect in November 2006.2006.

• Legislative Intent of Enabling Statute:Legislative Intent of Enabling Statute:11

– To create a more efficient and accountable structure;To create a more efficient and accountable structure;– To reorganize and streamline the state's process of detecting and To reorganize and streamline the state's process of detecting and

combating Medicaid fraud and abuse; and combating Medicaid fraud and abuse; and – To maximize the recoupment of improper Medicaid payments.To maximize the recoupment of improper Medicaid payments.

• Requirement for Providers to Adopt Effective Compliance Programs:Requirement for Providers to Adopt Effective Compliance Programs:22 – ““The legislature determines that there are key components that must be The legislature determines that there are key components that must be

included in every compliance program and such components should be included in every compliance program and such components should be required if a provider is to be a medical assistance program participant.”required if a provider is to be a medical assistance program participant.”

12006 N.Y. Laws, Chapter 442; N.Y. Public Health Law § 30.2 N.Y. Social Services Law § 363-d.

OMIG’s MissionOMIG’s Mission

Our mission is to preserve the integrity Our mission is to preserve the integrity of the New York State Medicaid of the New York State Medicaid program program by preventing and detecting by preventing and detecting fraudulent, abusive and wasteful fraudulent, abusive and wasteful practicespractices within the Medicaid within the Medicaid program and program and recovering improperly recovering improperly expended Medicaid fundsexpended Medicaid funds..11

1 N.Y. Public Health Law § 31.

““Abuse” & “Improper Payments”Abuse” & “Improper Payments”• AbuseAbuse

– ““Abuse means practices that are inconsistent with sound . . . medical or Abuse means practices that are inconsistent with sound . . . medical or professional practices and which result in unnecessary costs . . ., payment professional practices and which result in unnecessary costs . . ., payment for services which were not medically necessary, or payments for services for services which were not medically necessary, or payments for services which fail to meet recognized standards for health care.”which fail to meet recognized standards for health care.”11

– Similar provisions in other states.Similar provisions in other states.• Improper PaymentsImproper Payments

– An improper payment is “any payment that should not have been made or An improper payment is “any payment that should not have been made or that was made in an incorrect amount (including overpayments and that was made in an incorrect amount (including overpayments and underpayments) under . . . legally applicable requirements.”underpayments) under . . . legally applicable requirements.”22

• 1-18 NYCRR § 515.1(b)(1). • 2 Federal Improper Payments Information Act of 2002;

Improper Payments – Progress Made But Challenges Remain In Estimating and Reducing Improper Payments, GAO-09-628T (U.S. Government Accountability Office, April 22, 2009).

The Work of OMIGThe Work of OMIG

• Audit and Review PaymentsAudit and Review Payments– Over 2000 final audits since October 1, 2008 (completed Over 2000 final audits since October 1, 2008 (completed

and posted on website)and posted on website)• Investigate Improper PaymentsInvestigate Improper Payments

– Causes, intent, extentCauses, intent, extent• Educate Providers on Requirements and Compliance Educate Providers on Requirements and Compliance

Methods, and Audit ResultsMethods, and Audit Results• Receive reports, refunds, and explanations of Receive reports, refunds, and explanations of

overpayments from providers under PPACA 6402overpayments from providers under PPACA 6402• Prevent Improper Payments (including exclusion of problem Prevent Improper Payments (including exclusion of problem

providers)providers)• Refer and/or Assist Fraudulent Provider Prosecutions (by Refer and/or Assist Fraudulent Provider Prosecutions (by

Medicaid Fraud Unit, US Attorneys)Medicaid Fraud Unit, US Attorneys)• Identify and Recover Payments Where Another Insuror is Identify and Recover Payments Where Another Insuror is

ResponsibleResponsible

THE WORK OF OMIG-AUDITTHE WORK OF OMIG-AUDIT

• FIELD REVIEWS-IMPROVEMENTSFIELD REVIEWS-IMPROVEMENTS• At entrance conference, PPT lays out scope, At entrance conference, PPT lays out scope,

purpose of audit, authority for auditpurpose of audit, authority for audit• During audit, auditors expected to communicate During audit, auditors expected to communicate

what they are findingwhat they are finding• At exit conference, summary sheet lays out At exit conference, summary sheet lays out

reasons for disallowance of sampled claimsreasons for disallowance of sampled claims• Provider has opportunity during audit, after exit Provider has opportunity during audit, after exit

conference, after draft audit to provide more conference, after draft audit to provide more information or rebut findingsinformation or rebut findings

• New work plan will lay out sampling methodology New work plan will lay out sampling methodology in greater detail in greater detail

THE WORK OF OMIG-AUDITTHE WORK OF OMIG-AUDIT

• FOCUS ON MEDICAL RECORDS AND ORDERSFOCUS ON MEDICAL RECORDS AND ORDERS• IF SERVICE IS NOT DOCUMENTED, CANNOT BE IF SERVICE IS NOT DOCUMENTED, CANNOT BE

BILLEDBILLED• AUDIT TO REGULATION AND STATE PLANAUDIT TO REGULATION AND STATE PLAN• BUT-IF YOU HAVE WRITTEN STATEMENT BY DOH BUT-IF YOU HAVE WRITTEN STATEMENT BY DOH

AUTHORIZING BILLING, OR WRITTEN RECORD OF AUTHORIZING BILLING, OR WRITTEN RECORD OF ORAL STATEMENT,WE WILL GIVE THE BENEFIT OF ORAL STATEMENT,WE WILL GIVE THE BENEFIT OF DOUBT TO PROVIDERDOUBT TO PROVIDER

• IT IS NOT ENOUGH TO SAY “WE ALWAYS BILLED IT IS NOT ENOUGH TO SAY “WE ALWAYS BILLED THIS WAY AND THEY ALWAYS PAID US.” THIS WAY AND THEY ALWAYS PAID US.”

THE WORK OF OMIG-AUDIT THE WORK OF OMIG-AUDIT

• NURSING FACILITY REBASING SCHEMESNURSING FACILITY REBASING SCHEMES• PERSONAL CARS ON COST REPORTPERSONAL CARS ON COST REPORT• NO PHYSICIAN ORDERS FOR SERVICES, NO PHYSICIAN ORDERS FOR SERVICES,

DRUGS, OR SUPPLIESDRUGS, OR SUPPLIES• FORGED PHYSICIAN ORDERSFORGED PHYSICIAN ORDERS• 8 HOURS OF WALKING FOR HOMEBOUND 8 HOURS OF WALKING FOR HOMEBOUND

HOME HEALTH PATIENTHOME HEALTH PATIENT• NO RECORD OF THRESHOLD SERVICE IN NO RECORD OF THRESHOLD SERVICE IN

CLINICCLINIC

OMIG IS A PROGRAM INTEGRITY OMIG IS A PROGRAM INTEGRITY AGENCYAGENCY

• Focus on business processes, self-regulation, information Focus on business processes, self-regulation, information • Deter and discourage improper payments on front endDeter and discourage improper payments on front end

– Compliance Compliance – Clear, auditable rulesClear, auditable rules– Program editsProgram edits– Audit planAudit plan– Data miningData mining– Communicate efforts and results Communicate efforts and results

• Recover improper payments quicklyRecover improper payments quickly• Keep bad (quality or honesty) providers outKeep bad (quality or honesty) providers out• Investigate and refer fraudulent conduct Investigate and refer fraudulent conduct

OMIG CORE PRINCIPLE: SOCIAL OMIG CORE PRINCIPLE: SOCIAL SERVICES LAW 363-d REQUIRES SERVICES LAW 363-d REQUIRES OF ALL MEDICAID PROVIDERS OF ALL MEDICAID PROVIDERS OVER $500,000OVER $500,000

• 18 NYCRR 521-Regulation-”effective 18 NYCRR 521-Regulation-”effective compliance program” with eight compliance program” with eight elementselements

• Frequently Asked QuestionsFrequently Asked Questions

• www.omig.ny.gov www.omig.ny.gov

• Upcoming Webinar on compliance in Upcoming Webinar on compliance in NovemberNovember

Core OMIG Principle:Core OMIG Principle:Collaborate with Providers to Collaborate with Providers to Enhance ComplianceEnhance Compliance

• Program Integrity on Front-End (four “R”s)Program Integrity on Front-End (four “R”s)– Require, Recommend, Review and Reward effective Require, Recommend, Review and Reward effective

compliance programscompliance programs• ““Effective” Compliance Program ReviewsEffective” Compliance Program Reviews

– Disclosure to state of overpayments received, when Disclosure to state of overpayments received, when identified (over 80 disclosures in 2009, over 130 to date in identified (over 80 disclosures in 2009, over 130 to date in 2010) (PPACA webinar, Exclusions webinar on website.)2010) (PPACA webinar, Exclusions webinar on website.)

– Certification completed?Certification completed?– Risk assessment, audit and data analysis, remedial Risk assessment, audit and data analysis, remedial

measures (elements 6 and 7)measures (elements 6 and 7)– Credit balance obligationsCredit balance obligations

Core OMIG Principle:Core OMIG Principle:Communicate, Promote Communicate, Promote Transparency and FairnessTransparency and Fairness

• Annual work plan posted on website-FFY Annual work plan posted on website-FFY 2011 shortly 2011 shortly

• List of excluded persons on websiteList of excluded persons on website• Each final audit report on website Each final audit report on website

(approximately 2000 to date)(approximately 2000 to date)• Established audit protocols Established audit protocols • Audit survey to auditeesAudit survey to auditees• Over 80 presentations to trade and Over 80 presentations to trade and

professional groups each yearprofessional groups each year

Core OMIG PrinciplesCore OMIG Principles

• Promote High Quality of CarePromote High Quality of Care– OMIG will protect the health and welfare of NYS OMIG will protect the health and welfare of NYS

Medicaid enrollees by promoting Medicaid program Medicaid enrollees by promoting Medicaid program integrity at all levels of health care.integrity at all levels of health care.

• Promote Accountability and MeasurementPromote Accountability and Measurement– OMIG will be a good steward of the taxpayer’s dollar OMIG will be a good steward of the taxpayer’s dollar

and use the resources it has been given to efficiently and use the resources it has been given to efficiently and effectively accomplish its mission.and effectively accomplish its mission.

• Achieve and Exceed GoalsAchieve and Exceed Goals– OMIG will achieve or exceed externally defined OMIG will achieve or exceed externally defined

financial goals consistent with our legal standards financial goals consistent with our legal standards and audit rules, as demonstrated by complete, and audit rules, as demonstrated by complete, timely and accurate data.timely and accurate data.

Core OMIG Principle: Core OMIG Principle: ListenListen

• Recognize that every human institution can make Recognize that every human institution can make mistakes, and every administrative process can be mistakes, and every administrative process can be improved, particularly at an agency which is only improved, particularly at an agency which is only three years old. three years old.

• Take seriously the concerns raised by provider Take seriously the concerns raised by provider groups about the extent and nature of our audits and groups about the extent and nature of our audits and reviews, the training and performance of our staff, reviews, the training and performance of our staff, and techniques to improve our performanceand techniques to improve our performance

• Take seriously concerns raised by beneficiaries and Take seriously concerns raised by beneficiaries and beneficiary groups about the care received from beneficiary groups about the care received from providersproviders

Core OMIG Principle:Core OMIG Principle:Develop and Use Innovative Develop and Use Innovative Data Mining CapabilitiesData Mining Capabilities The Future of Medicaid Program Integrity Through Data The Future of Medicaid Program Integrity Through Data

MiningMining

• $200 Billion in claims in data warehouse$200 Billion in claims in data warehouse

• End-to-end integrationEnd-to-end integration

• Using new databases and analytic tools (Salient and others) Using new databases and analytic tools (Salient and others)

• Identify and communicate compliance data analysis Identify and communicate compliance data analysis processes which will identify problem at sourceprocesses which will identify problem at source

• Identify and communicate issues discovered through data Identify and communicate issues discovered through data miningmining

• Train and equip employees and organizations in data Train and equip employees and organizations in data analysis techniques analysis techniques

THE CHANGING LANDSCAPE OF DATA THE CHANGING LANDSCAPE OF DATA MINING AND PROVIDER RECOVERIES MINING AND PROVIDER RECOVERIES BY GOVERNMENTBY GOVERNMENT• Driven by the Improper Payments Act of 2002, and Deficit Driven by the Improper Payments Act of 2002, and Deficit

Reduction Act of 2005Reduction Act of 2005• What improper payments occur? Who gets them?What improper payments occur? Who gets them?• What systems and controls were in place (at payor, What systems and controls were in place (at payor,

provider, and enrollee) to prevent and detect improper provider, and enrollee) to prevent and detect improper payments?payments?

• What improvements are required to systems and controls What improvements are required to systems and controls to prevent recurrence?to prevent recurrence?

• Measurement of systems errorsMeasurement of systems errors• Using same systems approach to billing “errors” and never Using same systems approach to billing “errors” and never

events that has been developed for medical errors and events that has been developed for medical errors and never events never events

Data MiningData Mining

• We need to balance sensitivity (ability to We need to balance sensitivity (ability to detect improper payments) vs. reliability (risk detect improper payments) vs. reliability (risk of false positives)of false positives)

• High error rates/multiple attributesHigh error rates/multiple attributes• Fair treatment, due process, prompt resolutionFair treatment, due process, prompt resolution• Ultimate goal - providers should be able to Ultimate goal - providers should be able to

build data mining systems in on front end, not build data mining systems in on front end, not wait for government detection of improper wait for government detection of improper claims claims

• Ultimate goal-disclosures by providers of Ultimate goal-disclosures by providers of identified errorsidentified errors

DATA MINING IN HEALTH CARE-DATA MINING IN HEALTH CARE-TRADITIONAL FOCUS ON TRADITIONAL FOCUS ON CLAIM, NOT PROVIDERCLAIM, NOT PROVIDER• CMS-National Correct Coding Initiative CMS-National Correct Coding Initiative

Coding Policy Manual for Medicare ServicesCoding Policy Manual for Medicare Services• Claimcheck (McKesson product)-how does this Claimcheck (McKesson product)-how does this

claim pass two million editsclaim pass two million edits• NY EMEDNY system-several thousand edits (refill NY EMEDNY system-several thousand edits (refill

too soon, subject to prior approval, deceased too soon, subject to prior approval, deceased patient)patient)

• Ingenix Claims editing KnowledgebaseIngenix Claims editing Knowledgebase• Claims Clearinghouse reviews  Claims Clearinghouse reviews  • IPRO observation bed and DRG reviewsIPRO observation bed and DRG reviews

DATA MINING IN HEALTH CARE-DATA MINING IN HEALTH CARE-MOVING BEYOND FOCUS ON MOVING BEYOND FOCUS ON CLAIM CLAIM • Disease states (ICD-9)Disease states (ICD-9)

• Claims history (this provider)Claims history (this provider)

• Claims history (all providers)Claims history (all providers)

• Encounter data-this providerEncounter data-this provider

• Demographic data from external sourcesDemographic data from external sources

• Regression analysis-run patients or Regression analysis-run patients or providers with this result backwardsproviders with this result backwards

• Attempts by this providerAttempts by this provider

OMIG DATA MINING OMIG DATA MINING INITIATIVESINITIATIVES

• IDENTIFYING CAUSES OF IMPROPER IDENTIFYING CAUSES OF IMPROPER PAYMENTS: THE DECEASED PAYMENTS: THE DECEASED PATIENTS PROJECTPATIENTS PROJECT

• Billing by Medicaid providers for Billing by Medicaid providers for months after October 2009months after October 2009

• 300 deceased patients billed for 300 deceased patients billed for month; number drops with each month; number drops with each mailingmailing

THE DECEASED PATIENTS THE DECEASED PATIENTS PROJECTPROJECT

• ““NOT DEAD”NOT DEAD”

• BILLING ERRORBILLING ERROR

• SILENCE-two monthsSILENCE-two months

• BORN AGAIN (OR AT LEAST BORN AGAIN (OR AT LEAST REENROLLED)REENROLLED)

• RULES ALLOW BILLINGRULES ALLOW BILLING

PAYMENTS FOR DECEASED PAYMENTS FOR DECEASED PATIENTS PROJECTPATIENTS PROJECT

• PATIENT’S BODY TRANSFERRED TO PATIENT’S BODY TRANSFERRED TO TEACHING HOSPITAL AFTER DEATH FOR TEACHING HOSPITAL AFTER DEATH FOR ORGAN HARVESTING-CODED AS ADMISSIONORGAN HARVESTING-CODED AS ADMISSION

• PATIENT’S MEDICAID NUMBER VISITED THREE PATIENT’S MEDICAID NUMBER VISITED THREE DENTAL CLINICS IN WEEK AFTER DEATHDENTAL CLINICS IN WEEK AFTER DEATH

• PICKUP OF CONTROLLED SUBSTANCES BY PICKUP OF CONTROLLED SUBSTANCES BY PARTNER AFTER PATIENT DEATHPARTNER AFTER PATIENT DEATH

• DELIVERY OF BED AFTER PATIENT DEATHDELIVERY OF BED AFTER PATIENT DEATH• ROSTER BILLINGROSTER BILLING

DATA MINING: CREDENTIALING DATA MINING: CREDENTIALING AND EXCLUSIONAND EXCLUSION• WHERE ARE THEY NOW? PROBLEM DOCTORS , WHERE ARE THEY NOW? PROBLEM DOCTORS ,

NURSES, PHARMACISTS, THERAPISTS, AND NURSES, PHARMACISTS, THERAPISTS, AND PROVIDERS-STRAIGHTFORWARD FALSE CLAIM PROVIDERS-STRAIGHTFORWARD FALSE CLAIM ACTION-CMS, OIG CITE 1999 STANDARDACTION-CMS, OIG CITE 1999 STANDARD

• KEEPING BAD AND EXCLUDED PROVIDERS OUT KEEPING BAD AND EXCLUDED PROVIDERS OUT OF HEALTH CARE- USING AUTOMATED OF HEALTH CARE- USING AUTOMATED BACKGROUND CHECKS, PRIOR LICENSE ACTIONS, BACKGROUND CHECKS, PRIOR LICENSE ACTIONS, PRIOR EXCLUSIONS (state and federal) PRIOR EXCLUSIONS (state and federal)

• CMS and OIG-all billing for services provided or CMS and OIG-all billing for services provided or ordered by excluded persons cannot be paid from ordered by excluded persons cannot be paid from federal programsfederal programs

EXCLUSIONSEXCLUSIONS

• Section 1932(d)(1) of the Social Security Act prohibits organizations:

• from having an employment, consulting, or other agreement with an individual or entity for the provision of items and services that are significant and material to the entity’s obligations under its contract with the State where the individual or entity is debarred, suspended, or excluded.

Effect of Exclusion From Effect of Exclusion From Participation in Medicaid Participation in Medicaid

• September 1999 OIG bulletinSeptember 1999 OIG bulletin• No excluded person can receive any No excluded person can receive any

compensation from federal health care compensation from federal health care programsprograms

• In effect, this bars even janitors if their In effect, this bars even janitors if their compensation is derived in any part from compensation is derived in any part from MedicaidMedicaid

• http://www.oig.hhs.gov/fraud/docs/http://www.oig.hhs.gov/fraud/docs/alertsandbulletins/effected.htmalertsandbulletins/effected.htm

Provider Exclusions – Provider Exclusions – State Medicaid Directors Letter 08-State Medicaid Directors Letter 08-003 and 09-001 (available on CMS 003 and 09-001 (available on CMS website)website)

• Issued on June 12, 2008 and January 2009Issued on June 12, 2008 and January 2009

• Reminds States of their duty to report to HHS-Reminds States of their duty to report to HHS-OIG about excluded personsOIG about excluded persons

• Reminds States of the consequences of paying Reminds States of the consequences of paying excluded providersexcluded providers

• Recommends that providers screen Recommends that providers screen employees and contractors for excluded employees and contractors for excluded individuals both prior to hiring and contracting individuals both prior to hiring and contracting and periodically thereafter and periodically thereafter

Data MiningData MiningPayment Controls & MonitoringPayment Controls & Monitoring

• POS card swipe machines to ensure POS card swipe machines to ensure member is present when service allegedly member is present when service allegedly was performed-real time reportingwas performed-real time reporting

• Selection of providers with high improper Selection of providers with high improper payment rates for prepayment review of payment rates for prepayment review of claimsclaims

• Home health worker call in on arrival or Home health worker call in on arrival or departure from patient homedeparture from patient home

• Edit 1141-prepayment reviewEdit 1141-prepayment review• GPS on ambulettesGPS on ambulettes

MedicaidMedicaidData Matches/Demographics-What Data Matches/Demographics-What

Projects Tell Us About Provider Projects Tell Us About Provider

Systems?Systems? • Men having babiesMen having babies

• Fillings in crownsFillings in crowns

• Deceased enrolleesDeceased enrollees

• Home health services during hospital Home health services during hospital staystay

• Prescriptions filled during hospital stayPrescriptions filled during hospital stay

• OIG/HHS – “high error rate providers”OIG/HHS – “high error rate providers”

ConclusionConclusion

• COMMITMENT TO FAIR PROCESS AND TRANSPARENCY COMMITMENT TO FAIR PROCESS AND TRANSPARENCY • COMMITMENT TO LISTEN TO AND ADDRESS CONCERNS COMMITMENT TO LISTEN TO AND ADDRESS CONCERNS

RAISED BY PROVIDERS AND BENEFICIARIESRAISED BY PROVIDERS AND BENEFICIARIES• IDENTIFY, MEASURE AND ADDRESS SYSTEMS CAUSES OF IDENTIFY, MEASURE AND ADDRESS SYSTEMS CAUSES OF

IMPROPER PAYMENTSIMPROPER PAYMENTS• FOCUS ON PROVIDERS AND NETWORKS, NOT JUST CLAIMSFOCUS ON PROVIDERS AND NETWORKS, NOT JUST CLAIMS• GOVERNMENT NEEDS TO FIND WAYS TO GET RESULTS OF GOVERNMENT NEEDS TO FIND WAYS TO GET RESULTS OF

DATA MINING AND AUDIT INTO HANDS OF PROVIDERS AND DATA MINING AND AUDIT INTO HANDS OF PROVIDERS AND ASSOCIATIONSASSOCIATIONS

• PROVIDERS NEED TO RESPOND THROUGH SYSTEMATIC PROVIDERS NEED TO RESPOND THROUGH SYSTEMATIC COMPLIANCE EFFORTS TO INFORMATION FROM DATA COMPLIANCE EFFORTS TO INFORMATION FROM DATA MINING AND AUDIT MINING AND AUDIT

FREE STUFF FREE STUFF

• Mandatory compliance program-hospitals, Mandatory compliance program-hospitals, managed care, all providers over managed care, all providers over $500,000/year$500,000/year

• Over 1500 provider audit reports, detailing Over 1500 provider audit reports, detailing findings in specific industry findings in specific industry

• 2010-11 work plan issued shortly Listserv 2010-11 work plan issued shortly Listserv (put your name in, get emailed updates)(put your name in, get emailed updates)

• New York excluded provider list OMIG New York excluded provider list OMIG website-WWW.OMIG.NY.GOVwebsite-WWW.OMIG.NY.GOV