0. OMIG\HMS Integrated Reviews & Provider Portal
Cerebral Palsy Associations of New York State
April 2011

1. Today’s Objectives Describe OMIG’s new approach to payment recapture
Demonstrate how this approach can help optimize recoveries and minimize abrasion
Provide an overview of the OMIG/HMS Provider Portal
We have three objectives today.
I’m going to talk about a new and innovative approach to “payment capture”
I’ll talk about how this approach can help Medicaid agencies optimize recoveries, minimize abrasion, and prevent future overpayments.
And, finally, I’ll give you some specific ideas you can start to implement right away to impact your results. 1 1

2. Where We Are Now TPL PI Provider self-disclosure Data matching
Cost avoidance
Third party reviews
Estate and casualty recovery
Direct billing
Disallowances
TPL PI
Provider self-disclosure
Onsite and desk reviews
Credit balance reviews
Data mining
Long-term care review
Institutional reviews
As we began to approach our recovery efforts in a more holistic way, the line between some of our TPL efforts and some of our PI efforts began to blur.
So, for example, our onsite and desk reviews, our data mining efforts, and our long-term care reviews were both addressing TPL and PI overpayments.
We enacted changes to NYS Insurance and Social Services laws in 2009 pursuant to the Deficit Reduction Act of 2005 in order to optimize our recovery opportunities and obtain additional third party payor data: specifically, paid claims. Paid claims will play a large role in shaping our PI programs and I will talk more about this later on in the slide.
In the meantime, adopting the DRA and how we used that regulation to improve our positioning on Program Integrity is yet another illustration that there is a lot to be gained from the integrated approach.
Where TPL and Program Integrity efforts are coordinated, there’s more opportunity to increase recoveries, save costs, and prevent provider abrasion.

3. Where We Are Headed INTEGRATION Provider disclosure Cost avoidance
Payment integrity reviews
e-Reviews
Data matching
Third party reviews
Institutional reviews
Estate and casualty recovery
Fraud referrals
Onsite and desk reviews
Disallowances
New York is in the process of enhancing its payment capture efforts through integrated and streamlined Reviews. Key objectives:
1. Multiple overpayment reasons (minimizes provider abrasion)
2. Improve provider education
3. Tools to stop the bleeding (sentinel effect, better compliance)
Let me take you through our vision.
Data mining
Long-term care reviews
Direct billing
Free standing clinic reviews
Provider scoring

4. ACA Increases Focus on Program
Section 6402(a) of Affordable Care Act (ACA) requires providers to “report and return” overpayments
Section 6411(a) requires states to establish contract(s) with one or more Medicaid Recovery Audit Contractors
Funding to combat fraud, waste and abuse
NYS OMIG was working on an integrated solution before PPACA.
The Patient Protection and Affordable Care Act (PPACA) includes a number of requirements that directly impact “payment recapture” programs.
One, PPACA mandates provider self-disclosure and the return of “identified” overpayments within 60 days. Providers who fail to do so face potential liability under the Fraud enforcement and recovery Act of New York State is assessing how to enforce provider disclosures as part of our integrated approach to identifying overpayments. We’ll talk more about this a little later on.
Two, PPACA requires all Medicaid programs to contract with at least one RAC on a contingency basis by the end of this calendar year.
Three, PPACA provides $700 million over the next decade in new funds to fight fraud. CMS will be holding payors increasingly responsible for making sure that Federal dollars are spent appropriately.
All of these changes, especially the first two, impact every program integrity and compliance program; and each program will likely have to make some adjustments. At the same time, we view these changes as opportunities to strengthen PI and compliance programs. For example, the mandatory self-disclosure rule -- New York OMIG views this as a “game changer.” With a federal regulation that places duties on providers to return overpayments OMIG will be shifting focus from pure recoveries where OMIG drove the identification and recovery to a more compliance approach to ensuring providers take this mandate seriously.
Together, all of these factors are driving Medicaid efforts to identify and collect on overpayments. In other words, these regulations – and particularly mandatory self-disclosure – represent a paradigm shift to clearly place duties on providers to “report and return” Medicaid overpayments. NY is making program adjustments to take advantage of this shift.

5. NY Medicaid RAC Program
OMIG has designated HMS as the New York Medicaid RAC with CMS’s approval of the SPA
Integrated approach shares data across programs
Maximize identification of payment issues
Reduce future overpayments
Minimize provider burden
The “integrated approach” will be a central piece to New York OMIG Medicaid RAC Program
Again, we are already starting to benefit from this approach, with more recoveries. And we’re doing it without experiencing provider appeals.
And, finally, with CMS’s mandate for contingency fee-based Medicaid RAC programs, it’s possible that many of these efforts will meet CMS’s requirements under PPACA.

6. Integrated Approach
I would like to spend a minute and talk about the front end edits within MMIS and provide a point of reference to where our integrated approach fits within the big picture. As everyone here knows, providers submit claims to MMIS and the system begins adjudicating claims. During adjudication MMIS checks for:
Medicaid Eligibility
Coding
Third Party resources
-And just to give you an idea, NY MMIS has over one million lines of codes.
By and large, MMIS flags most issues during adjudication and denies erroneous claims. However, not every issue can be identified at the point of adjudication – in fact certain types of overpayments don’t become an overpayment until after the fact. This is true of any claiming platform and further supported by the fact that every Medicaid program and every payor for that matter has programs aimed at recovering overpayments.
The following describes how OMIG is addressing this universal need through an integrated approach.

7. Integrated Approach
Upon adjudication, claims are paid

8. Integrated Approach
The “integrated approach” begins with Provider Self-Disclosure. Providers are responsible for reviewing Medicaid payments and ensuring that they received payments for the correct service and for the correct amount
OMIG has begun to mail letters prompting providers to conduct a self-review and disclose confirmed overpayments
OMIG plans to leverage a current vendor to develop a web-based portal
Give providers a self-service tool for disclosing overpayments
Portal to capture refund reasons and amounts electronically
Plan is to allow providers ability to query claims data in order to minimize data entry while improving accuracy of self-disclosures
Other tools will be available to allow the process to be as simple as possible
Plan is to leverage the existing registration information on the Provider Website for Third Party Reviews – 1,703 registered users, 941 unique provider ID #s – and also conduct outreach campaigns
4. Let’s talk for a minute about the interpretation of the PPACA rule that says that an overpayment must be reported and returned by the later of (a) the data which is 60 days after the date on which the overpayment was “identified” or (b) the date on which any corresponding cost report is due, if applicable.
DISCUSS OMIG INTERPRETATION BRIEFLY
Provider billing and payment system shows credit balance after posting of payments
Employee or contractor identifies overpayment in hotline call or to provider
Qui tam or government lawsuit allegations disclosed to provider
Criminal indictment or information 8 8

9. Integrated Approach
OMIG continues to review provider Aged Trial Balance reports, selecting providers for onsite and desk reviews. We are notifying providers by mail, and asking them to supply additional reports necessary for the review. Provider attestation will be required at review closing.
We also conduct data mining to determine whether there are potential overpayments not disclosed on provider ATBs.
We continue to run existing algorithms while developing new ones
Targeted claims are reviewed through onsite or desk reviews—or along with the ATB review 9 9

10. Integrated Approach
The next step in this approach are what we call “e-reviews.” It’s worth spending a little time on this.
We are launching a game-changing approach to data mining, where we’ll be using external data to identify overpayments in a more precise way.
GO TO NEXT SLIDE

11. e-Reviews and Data Mining
Uses paid claims data from third party payors and other external data
Commercial
Medicare
Provider A/R (Credit & Debit Balances)
Allows for validation of overpayment at time of data mining
Notifies providers via mail and portal
Recoveries may be initiated electronically through MMIS
We are in the process of obtaining Paid Claims data from more than 16 payors, and we are pursuing Medicare paid claims data.
By using external data, we can validate overpayments at the point of data mining.
Providers will be notified through mail—and eventually through the web-based portal.
This initiative expands the scope of our data mining efforts to other provider types, including
Stand-alone clinics
Medical suppliers
Pharmacy
Medi-Medi on steroids 11 11

12. e-Reviews and Data Mining (cont.)
More emphasis on provider compliance and program oversight
Each overpayment is reviewed at the claim level
Drives the integration of TPL and PI through data mining
[click when you are ready to highlight the last bullet]
NEED TO UPDATE NOTES ON THIS SLIDE
This slide is about “why” eReview and Data Mining makes sense - e.g. 1) gives the state tremendous leverage; 2) shifting from pure recovery programs to compliance programs. 12 12

13. Integrated Approach
Identify potential fraud cases 13 13

14. Integrated Approach
Who’s showing up across multiple overpayment scenarios
Will be looking for aberrant behaviors
Frequency of self-disclosure
Overpayment reasons
Who finds the overpayments (provider vs. OMIG)

15. Integrated Approach Sentinel Effect = Improved Provider Billing 15
In summary, what we’re learning is that regardless of what program is catching an overpayment—TPL or Program Integrity, the goal is the same—to identify the overpayment, recover the dollars, identify the root cause, and then work with providers to ensure the overpayment doesn’t happen again.
This new integrated approach is a comprehensive “payment recapture” program- -integrating individual TPL and PI programs into tiers – one program feeding into the other. We expect to see more recoveries, a reduction in future overpayments, and minimal provider abrasion.
Sentinel Effect = Improved Provider Billing 15 15

16. OMIG/HMS Provider Portal
Question:
How are we going to work with the providers to help consolidate and streamline review distribution, reconciliation and recovery processing?
Answer:
OMIG/HMS Provider Portal 16

17. Overview of the Provider Portal
The Provider Portal is a web-based application that will allow providers a single point of entry for multiple OMIG reviews
The provider portal is designed to accommodate multiple functionalities
Third Party Reviews
Payment Integrity Reviews
Provider Self-Disclosures
Medicaid Credit Balance Reporting 17

18. Accessing The Provider Portal
Web-based with 128-bit security encryption
Login for existing users and requesting a user account

19. New User Registration
Select Registration Type to pull up the appropriate registration form
Once the registration form has been submitted the new user will contacted by HMS to verify information

20. First Time Access Enter a new personalized password and confirm
Enter the Current Password given to the provider by HMS during the registration process
Select security questions and answers
Click OK

21. Home Page
Select Application/Project

22. Third Party Reviews
Each Third Party Review is assigned a “cycle number”.
“Cycle Search” allows the user to search for a specific review.
Once you have selected the appropriate Third Party Review click to open

23. Third Party Reviews (cont)
“Recipient Search” function allows the user to pull up all the claims that appeared on Third Party Reviews that belong to a specific patient
Click to view claim detail

24. Third Party Reviews (cont)
“Claim Search” function allows the user to pull up a specific claim that appeared on a Third Party Review
Click to view claim detail

25. Responding to Third Party Reviews (cont)
Information identifying cycle number, recipient, and third party coverage
Claim Information
Click on the down arrow of “Provider Action/Reasons” to select the appropriate Action/Reasons code
Click “Ok” to save the Action/Reasons code and Provider Comments or click “Cancel” to discard changes and exit.
Enter comments regarding the claim in the “Provider Comments” box

26. Payment Integrity Reviews
Types of Payment Integrity Reviews
Automated Reviews (e-Reviews)
Consists of overpayments that can identified with extremely high accuracy
Provider will be given 30 days to review findings
Complex Reviews
Potential overpayments where additional information is required to make a clear determination
Providers required to submit documentation to HMS
HMS reviews the documentation and makes a determination
Reviews will be sent to providers in a similar fashion as TPR
Target overpayments through data mining
Upload targets to the Portal and notify providers
Providers given clear instructions on how to satisfy each type of review

27. Self-Disclosures
Upon logging into the provider, users with appropriate will see the Self-Disclosure application listed on their home page.
Click “Select” to access the application.

28. Self-Disclosures – Input
Enter basic claim information needed to identify the claim
Enter recipient’s information
Enter primary payor and payment information (if applicable)
Enter refund amount and reason(s) for overpayment
Click “Submit” to submit the report to the “Supervisor” for final review
As refunds are entered and saved, they appear at the bottom of the screen

29. Self-Disclosures – Search
Each user is allowed to query for refunds they entered and/or submitted.
Users with “Supervisor” access will be able to query all refund entries for the given provider/facility.
Query options. Enter the search criteria and click “Search”
Search results are returned at the bottom of the page
Click “Details” to view full information on file
Click “Export” to export search results to an Excel spreadsheet

30. Self-Disclosures – Attestation
Only the users with “Supervisor” access will be able to formally submit self-disclosures to OMIG-HMS. When submitting the final report, the “Supervisor” will be asked to attest to the information being submitted.

31. Medicaid Credit Balance Reporting
Batch Reporting
Will give providers the ability to upload completed worksheets with proper attestation, eliminating claim by claim data entry and reporting
Supply a report template for providers to use
May require providers who chose to use batch reporting to under-go acceptance testing to verify correct formatting, accuracy of data, etc.
Will mirror OMIG initiative to prompt self-disclosures

32. What to Watch for in 2011 Third Party Reviews Self-Disclosures
Outreach underway to re-register providers to the OMIG-HMS Portal
Anticipate uploading the first Review to the portal around March 21th
Self-Disclosures
Development completed
Currently in the User Acceptance Testing (UAT) Phase
Looking for initial rollout to a small group of hospitals around April 25th
Will seek feedback from the early adopters
Credit Balance Reporting
Currently in the design phase
Anticipating 3 month development and testing
Payment Integrity Reviews
Anticipating 6 month development and testing

33. Timeline March 21, 2011 Third Party Reviews
April 25, Self-Disclosures
July 1, Credit Balance Reporting
October 1, Payment Integrity Reviews