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The Office of the Medicaid Inspector General

Combating Fraud, Waste, and Abuse in the

Arkansas Medicaid Program

Bart Dickinson, Chief Counsel

Office of the Medicaid Inspector General

The Office of Medicaid Inspector General shall

prevent, detect, and investigate fraud, and

abuse within the medical assistance program.

- Ark. Code Ann. §20-77-2505

The Office of the Medicaid Inspector General

fulfills the federal program integrity

requirement to ensure compliance, efficiency,

and accountability within the Medicaid

program by detecting and preventing fraud,

waste, and abuse under - 42 CFR §455 et al.

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OMIG focusVerify Medicaid services and claims were furnished and

properly billed for eligible beneficiaries;

Recover improperly expended payments;

Report fraud and abuse to appropriate law enforcement;

Recommend and implement changes to the Medicaid

program.

Who is HFMA?

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OMIG Agency Work plan

• Audit and Review Medicaid Providers

• Federal Program Integrity requirements

• Investigate, Suspend, and Exclude Providers

• Recommend and Implement reform

• Develop Initiatives to curb Fraud, Waste, and

Abuse in Medicaid programs

• Educate Medicaid Providers

Data Analysis and Audit Selection

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Selecting Medicaid Providers for Audit and Review

Highest Billers = Field Audit

Mid Level Billers = Self Audit Req.

High Billers = Desk Audit

Low Level Billers = Awareness Let.

Program Review / Change

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$0.00

$500,000.00

$1,000,000.00

$1,500,000.00

$2,000,000.00

$2,500,000.00

$3,000,000.00

$3,500,000.00

$4,000,000.00

FY 2013 - Division Medical

Services

FY 2014 FY 2015 FY2016 FY2017

5 Year Analysis of Medicaid Recoupments and Claims

$2.1 million$1.1 million$3.8 million$2.7 million$3 million

2017 OMIG Initiatives

Behavioral Health (Group Psychotherapy) OMIG recommendations• reduction to 4 daily units ( 1 hour) and 100 units per year passed

• work with DBHS/Beacon on Authorization for 911 and child population

• $14.5M reduction in Group Psych since October 2016 implementation

• Rate reduction from $13.80/unit to $10.00 withdrawn as compromise for BH Transformation reduction

could have been much higher. Have requested DHS review whether this reduction could be revisited.

Personal Care and Home Health Reform• August 3, 2016 – OMIG asked DHS & DMS to join in reform initiative and to assign all workers ID #

• Reform will help protect vulnerable population and reduce fraud, waste, and abuse.

• Other states like Alaska and Minnesota have realized significant savings to Medicaid programs.

• Recommendations to DHS/DMS for reform that could save millions each year

• Recommendations could provider better oversight, treatment, care, and protection

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2017 OMIG Initiatives

• Vision recommendations and reform

• Dental reviews and education

• Pharmacy recoveries and reform

• Hospital In-patient reviews

• School based therapy initiatives

• Dual Eligible Recipient recoveries and reviews

• Emergency and Non-Emergency transportation

2017 OMIG Initiatives• Behavioral Health Reform

• Transportation

• Vision, Dental & Pharmacy

• In-patient Hospital Stays

• School-Based Therapy

• Dual Eligible Recipients Payments

• Personal Care and Home Health Reform

• Medicaid Expansion Enrollment (Arkansas Works FFM)

Total Cost Savings Impact = $30 million

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CLAIMS % Increase Collections % increase

TOTALS: $3,791,902.58 28.44% $2,815,711.54 57.11%

OMIG Recoupments/Reversals/Claims and Collections

Agency spend

Total Agency Budget $2.68 million

Total Agency expenditures $2.35 million

“Turn Back” $330,000 (12.3%

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Extrapolation

The department shall not rely on the denial of one claim as

the sole basis for the denial of a subsequent claim and

shall establish that the subsequent claim is deficient.

Ark. Code Ann. §20-77-1703(f)

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New Mexico Medicaid Auditing Fiasco

OMIG Case Study in Fraud

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Data Analytics leads to Investigations

“As a provider, you are required to retain and

make records available . . .”

“Please compile and provide legible copies of

all the original patient records . . .”

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Data Analytics for Dodd• Date trends showed continued and excessive

billing even with fewer recipients being

provided services

Billing Cycle Patients Payments Avg. $$ per Patient

Jan-14 24 $ 24,260.32 $ 1,010.85

Mar-14 20 $ 20,924.24 $ 1,046.21

May-14 18 $ 18,336.96 $ 1,018.72

Jul-14 18 $ 27,459.18 $ 1,525.51

Sep-14 21 $ 40,443.90 $ 1,925.90

Nov-14 19 $ 34,618.25 $ 1,822.01

Jan-15 14 $ 21,151.72 $ 1,510.83

Mar-15 12 $ 24,061.16 $ 2,005.10

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What is your duty as an Accountant?

• Duty

– Ethical vs. Legal?

• Has your client/company evaded taxes?

• Is your client/company attempting to evade

taxes?

• What do you do? / Who do you contact?

• What is your exposure?

CPA Indictment

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Potential Criminal Exposure

The IRS also accepts complaints about tax return preparers who have committed fraud, and anyone with an issue may submit a complaint using Form 14157, Complaint: Tax Return Preparer. In-house accountants who cook the books or purposefully include erroneous data in their company's tax returns or accounting documents are responsible for misconduct and may even be criminally liable.

AccountantResponsibility http://www.investopedia.com/terms/a/accountant-esponsibility.asp#ixzz4oiYevki7

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Medicaid Fraud Self Report

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Medicaid Fraud Self Report

OMIG Website