METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER LEFT BEHIND James G. Sheehan Medicaid Inspector General

2011-Governor Cuomo: ”New York is at a crossroads” Budget challenges-$9-$10 billion deficit projection Budget challenges-$9-$10 billion deficit projection MRT (Medicaid Redesign Team) MRT (Medicaid Redesign Team) 79 agreed-upon Medicaid proposals now before Legislature 79 agreed-upon Medicaid proposals now before Legislature Budget deadline-April 1 Budget deadline-April 1

CORE QUESTIONS IN PROGRAM INTEGRITY How do we determine whether NY Medicaid and its patients get the services it is paying for? (actually rendered, ordered, needed, documented, minimum quality) How do we determine whether NY Medicaid and its patients get the services it is paying for? (actually rendered, ordered, needed, documented, minimum quality) Do NY Medicaid providers comply with their contractual requirements for payment? Do NY Medicaid providers comply with their contractual requirements for payment? How do we identify the providers most likely to fail in their compliance and patient care obligations? How do we identify the providers most likely to fail in their compliance and patient care obligations? What we do with these identified providers? What we do with these identified providers?

How do we determine whether NY Medicaid and its patients get the services it is paying for? Existing approaches: Existing approaches: –Field audits/desk audits (is there a physician order for the service? Is there a record the patient actually received the service?) –Data matches-billing for deceased patients, billing for home health during hospital stay –Third party payor reviews-are we paying for something someone else should pay for?

How do we determine whether NY Medicaid and its patients get the services it is paying for? Newer approaches Newer approaches –Clinical audits-do the services rendered and billed map against patient assessment and treatment plan of care? Why are patients with no prior diabetes diagnosis getting test strips? Has a physician who ordered $10 million in home health services actually seen and treated the patients for whom services are ordered?

How do we determine whether NY Medicaid and its patients get the services it is paying for? Newer approaches Newer approaches Data analysis on third party claim payment information received from private payors and Medicare Data analysis on third party claim payment information received from private payors and Medicare –Who got paid twice –Who charged us after payment in full by private payor –Who kept the money?

How do we determine whether NY Medicaid and its patients get the services it is paying for? Newer approaches Newer approaches –Medicaid Integrity Contractor (required by feds) –Medicaid RAC (required by feds) –Salient data mining Geographic mapping Geographic mapping Time mapping Time mapping Network analysis Network analysis Claim denial analysis Claim denial analysis

Do NY Medicaid providers comply with their contractual requirements for payment? Credentials Verification Reviews Credentials Verification Reviews Licenses, cons Licenses, cons Certifications Certifications Excluded persons ordering or providing Excluded persons ordering or providing Real addresses, real owners, service provided by billing entity? Real addresses, real owners, service provided by billing entity? Doctor “flophouses” rented by week Doctor “flophouses” rented by week Service bureaus Service bureaus

How do we identify the providers most likely to fail in their compliance and patient care obligations? Investigator’s technique: ask them when you already know the answer Investigator’s technique: ask them when you already know the answer Compliance technique: testing Compliance technique: testing “No provider left behind” “No provider left behind”

THE OMIG STORY-NO PROVIDER LEFT BEHIND New York’s Mandatory Compliance Program New York’s Mandatory Compliance Program Every Medicaid provider which receives or orders more than $500,000 in Medicaid reimbursed services must have an effective compliance program including 8 elements Every Medicaid provider which receives or orders more than $500,000 in Medicaid reimbursed services must have an effective compliance program including 8 elements Every Medicaid provider subject to requirements: Every Medicaid provider subject to requirements: –As of October 1, 2009 must have effective compliance program –As of December 31, 2009 must certify that it has an effective compliance program

THE OMIG STORY-NO PROVIDER LEFT BEHIND Every Medicaid provider which receives or orders more than $500,000 in Medicaid reimbursed services in 12 months must have an effective compliance program including 8 elements Every Medicaid provider which receives or orders more than $500,000 in Medicaid reimbursed services in 12 months must have an effective compliance program including 8 elements

FIRST COMPLIANCE YEAR EASY EXAM-SIGN YOUR NAME, SCORE 100 Every Medicaid provider subject to requirement must certify during December 2009 that it has an effective compliance program Every Medicaid provider subject to requirement must certify during December 2009 that it has an effective compliance program

HOW DID NY PROVIDERS DO ON THE EASY EXAM? AS OF APRIL 1, 2010, THREE MONTHS AFTER THE REQUIRED “SIGN YOUR NAME, GET 100” Exam... AS OF APRIL 1, 2010, THREE MONTHS AFTER THE REQUIRED “SIGN YOUR NAME, GET 100” Exam...

HOW DID NY PROVIDERS DO ON THE EASY EXAM? 50% flunked! 50% flunked!

Options when 50% flunk “no provider left behind” Blame the students (providers) Blame the students (providers) Blame the teachers (OMIG) Blame the teachers (OMIG) Blame the parents (Board, CEO) Blame the parents (Board, CEO) Figure out how to do better Figure out how to do better

EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL TELL YOU THE ANSWER-GIVE IT BACK TO US Letters to every non-certifying provider over $500,000 per year Letters to every non-certifying provider over $500,000 per year Personal visits and phone calls Personal visits and phone calls Webinars and trade association presentations Webinars and trade association presentations Detailed website instructions, discussion of consequences of non-certification Detailed website instructions, discussion of consequences of non-certification Extended deadline to October 1 Extended deadline to October 1 What happened? What happened?

EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL TELL YOU THE ANSWER- JUST GIVE IT BACK TO US 20% still flunked! 20% still flunked!

SECOND COMPLIANCE EXAM EASY EXAM-SIGN YOUR NAME, READ OUR CHEAT SHEET AND FOLLOW IT, SCORE 100 Show me the cheat sheet... Show me the cheat sheet...

New York State Social Services Law Section 363-d.Subsection 2 Certification by December 31 of each year-”effective” 18 NYCRR Section (c) A compliance program shall include the following 8 elements: Element 1: Written Policies and Procedures Element 1: Written Policies and Procedures Element 2: Designation of Compliance Officer Element 2: Designation of Compliance Officer Element 3: Training and Education Element 3: Training and Education Element 4: Communication lines to the Compliance Officer Element 4: Communication lines to the Compliance Officer Element 5: Disciplinary Policies Element 5: Disciplinary Policies Element 6: Identification of Compliance Risk Areas and non-compliance Element 6: Identification of Compliance Risk Areas and non-compliance Element 7: Responding to Compliance Issues Element 7: Responding to Compliance Issues Element 8:Policy of Non-Intimidation and Non-Retaliation Element 8:Policy of Non-Intimidation and Non-Retaliation New York: Eight Elements of Compliance Program; Certification of Compliance

New York Compliance Measurement Tool Cited by CMS as model Cited by CMS as model Available on OMIG website Available on OMIG website –

2011 NEW YORK COMPLIANCE How are we doing in 2011? How are we doing in 2011? –Somewhat better, but not as well as we hoped-even with organizations contacted in 2010 –OMIG is now doing on-site compliance reviews to assess the compliance programs of specific providers –Start with good ones for modeling –Move to weaker ones for intervention

2011 NEW YORK COMPLIANCE Universe of Providers by Provider ID paid or ordered over $1 million: 19,885 Universe of Providers by Provider ID paid or ordered over $1 million: 19,885 Providers by Provider ID paid or ordered over $1 million not certified (as of 3/10/11) 4,352 (22%) Providers by Provider ID paid or ordered over $1 million not certified (as of 3/10/11) 4,352 (22%) Universe of Providers by Provider ID paid or ordered over $5 million not certified: 234 Universe of Providers by Provider ID paid or ordered over $5 million not certified: 234 Small number of ordered over $1 million Small number of ordered over $1 million

WHAT SHOULD OMIG DO WITH ORGANIZATIONS WHICH DO NOT PASS THE EXAM? If you can’t pass an exam where you get a perfect score for signing your name, and we give you the correct answers, you probably aren’t doing a great job with your core health care mission or correct billing either If you can’t pass an exam where you get a perfect score for signing your name, and we give you the correct answers, you probably aren’t doing a great job with your core health care mission or correct billing either If you contract or have business relationships with organizations that do not or cannot certify, they may not be doing a great job with their contractual and care obligations to you and patients either If you contract or have business relationships with organizations that do not or cannot certify, they may not be doing a great job with their contractual and care obligations to you and patients either

How else do we identify the providers most likely to fail in their compliance and patient care obligations? Affordable Care Act Section 6402 Affordable Care Act Section 6402 Report, refund, and explain identified overpayments within 60 days of identification Report, refund, and explain identified overpayments within 60 days of identification Knowing failure to report= False Claims Act violation Knowing failure to report= False Claims Act violation “Zero is a bad number” “Zero is a bad number” 227 reports in 2010 is a good number 227 reports in 2010 is a good number Use self-disclosure protocol on OMIG website Use self-disclosure protocol on OMIG website

How else do we identify the providers most likely to fail in their compliance and patient care obligations? If they can’t pass the OMIG exam, which requires signing your name and reading the cheat sheet, how are they doing on the IRS exam? If they can’t pass the OMIG exam, which requires signing your name and reading the cheat sheet, how are they doing on the IRS exam?

IRS Form 990 Questions for Non-Profits on Governance Policies

NEW YORK: MEASURING COMPLIANCE PROGRAMS Telephone calls Telephone calls “Please connect me with your compliance officer” “Please connect me with your compliance officer” “How do you check for excluded persons among employees and contractors?” “How do you check for excluded persons among employees and contractors?” “We have not received your certification; could you send me a copy?” “We have not received your certification; could you send me a copy?” “How often do you meet with the Board or a board committee?” “How often do you meet with the Board or a board committee?” “Can we get a copy of your most recent IRS-990” “Can we get a copy of your most recent IRS-990”

How else do we identify the providers most likely to fail in their compliance and patient care obligations? Relationship mapping of problem providers Relationship mapping of problem providers “And then what happened?” followups to match projects, third party liability, audits for corrective action “And then what happened?” followups to match projects, third party liability, audits for corrective action Conflict and exception reports in home health Conflict and exception reports in home health hotline hotline

What can we do with the identified providers who cannot meet their compliance obligations? Call or write and ask why Call or write and ask why Post names of non-certifiers Post names of non-certifiers Reduce audit, investigative efforts on compliant organizations (and encourage other enforcement and regulatory entities to do so) Reduce audit, investigative efforts on compliant organizations (and encourage other enforcement and regulatory entities to do so) Terminate audits promptly where strong evidence of compliance Terminate audits promptly where strong evidence of compliance Increase audit, investigative, data analytic efforts on less compliant organizations Increase audit, investigative, data analytic efforts on less compliant organizations Look for common factors and relationships among less compliant providers (e.g., CEO indicted by US Department of Justice) Look for common factors and relationships among less compliant providers (e.g., CEO indicted by US Department of Justice)

AUDITING “EFFECTIVE” COMPLIANCE PROGRAMS Who is the compliance officer? Who is the compliance officer? To whom do they report? To whom do they report? Do employees and vendors know about the compliance program? Do employees and vendors know about the compliance program? Who does billing? How accurate is it? Who does billing? How accurate is it? Contingency fee contracting for coding and billing Contingency fee contracting for coding and billing FMV reviews of physician payments FMV reviews of physician payments Conflicts of interest Conflicts of interest Relationships with non-profits and the IRS form 990 Relationships with non-profits and the IRS form 990

OMIG PLANS TO INCREASE ITS FOCUS ON COMPLIANCE- CHALLENGED ORGANIZATIONS Audits Audits Data match followup Data match followup Salient analysis (geography, chronology, relationships) Salient analysis (geography, chronology, relationships) Investigations Investigations Exclusions Exclusions

WHAT SHOULD BUSINESS PARTNERS DO WITH ORGANIZATIONS WHICH DO NOT CERTIFY? If you can’t pass an exam where you get a perfect score for signing your name, and OMIG gives you the correct answers, you probably aren’t doing a great job with your core health care mission and your contractual and partner responsibilities either If you can’t pass an exam where you get a perfect score for signing your name, and OMIG gives you the correct answers, you probably aren’t doing a great job with your core health care mission and your contractual and partner responsibilities either

WHAT SHOULD BUSINESS PARTNERS DO WITH ORGANIZATIONS WHICH DO NOT CERTIFY? Call or write and ask why Call or write and ask why Raise issue to higher level in organization Raise issue to higher level in organization Investigator’s technique: ask them when you already know the answer Investigator’s technique: ask them when you already know the answer Compliance requirements Compliance requirements Element 6: Identification of Compliance Risk Areas and non-compliance Element 6: Identification of Compliance Risk Areas and non-compliance Element 7: Responding to Compliance Issues Element 7: Responding to Compliance Issues

Model compliance programs-hospitals, managed care (coming soon) and Compliance Alerts Model compliance programs-hospitals, managed care (coming soon) and Compliance Alerts Over 2000 provider audit reports, detailing findings in specific industry Over 2000 provider audit reports, detailing findings in specific industry Annual work plans Annual work plans New York excluded provider list New York excluded provider list Self-Disclosure protocol Self-Disclosure protocol Corporate Integrity Agreements Corporate Integrity Agreements Listserv Listserv Link to sites for all 18 states which currently publish their state exclusion lists Link to sites for all 18 states which currently publish their state exclusion lists FREE STUFF!