1. NC Department of Health and Human Services DMA Program Integrity: Medicaid Managed Care (1915 b/c Waivers) Patrick O. Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section Program Integrity October 26, 2012

2. NC Department of Health and Human Services DMA Program Integrity References/Authority: 42 CFR 438 (Managed Care) 42 CFR 434 (Contracts) 42 CFR 455 and 456 (Program Integrity & Utilization Control) NC Medicaid State Plan NCGS 108A – 70.10 thru 70.17 (False Claims) NCGS 108C (Medicaid and Health Choice Provider Requirements) 10A NCAC 22F (Program Integrity) soon to transfer to 10A NCAC 24F

3. NC Department of Health and Human Services DMA “Using the Power of the Medicaid Program to improve the standard of care for Medicaid recipients across the State of North Carolina”

4. NC Department of Health and Human Services DMA Mission Statement It is the mission of Program Integrity to ensure compliance, efficiency, and accountability within the N.C. Medicaid Program by detecting and preventing fraud, waste, program abuse, and by ensuring that Medicaid dollars are paid appropriately by implementing tort recoveries, pursuing recoupment, and identifying avenues for cost avoidance.

5. NC Department of Health and Human Services DMA Medicaid Landscape Medicaid Behavioral Health services are provided to recipients in all 100 North Carolina counties. The Current number of eligible Medicaid recipients is 1.5 million and HealthChoice is approximately 130,000 recipients with possible expansion by 2014. Over 14,000 Behavioral Health Providers (MH/SA/IDD)

6. NC Department of Health and Human Services DMA Objectives Participants will be able to: 1.Define fraud and abuse 2.Use PI toolkit as a template for MCO PI activities 3.Identify liaisons assigned to MCO 4. List the role & responsibilities of DMA PI Liaisons

7. NC Department of Health and Human Services DMA Objectives 5. List members of an Special Investigations Unit 6. Identify the roles and responsibilities of an SIU 7. Obtain knowledge regarding Managed Care Requirements IAW 42CFR 438 8. Understand DMA’s response to MCO referral

8. NC Department of Health and Human Services DMA Objectives 9. List items to report to DMA–PI on Attachment AA 10. Respond to MCO Investigation

9. NC Department of Health and Human Services DMA Program Integrity Toolkit for Success: Liaisons and contact information Federal regulations, State Statues, and Rules Program Integrity Policies, Procedures, and Processes Forms Audit and Review Tools MIU Referral & Supplemental Allegation Packets Copy of Presentation

10. NC Department of Health and Human Services DMA Program Integrity Provider Abuse Means provider practices that are inconsistent with sound fiscal, business, or medical practices, and results in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards of healthcare. It also includes recipient practices that result in unnecessary cost to the Medicaid program

11. NC Department of Health and Human Services DMA Program Integrity Provider Fraud 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 constitute fraud under applicable Federal or State law.

12. NC Department of Health and Human Services DMA Program Integrity Waste The misuse, underutilization, or overutilization of items or services or other inappropriate or unnecessary billing or medical practices that directly or indirectly add to healthcare costs or unwarranted or unexplained variation in care that results in no discernible differences in health or patient outcomes

13. NC Department of Health and Human Services DMA Program Integrity Quality of Care Concerns Clinical and practice issues that are identified by the utilization review during a review of clinical information submitted by providers for the purpose of requesting authorization to provide Medicaid funded behavioral health services; or Reported by a complainant about the care or services a recipient or consumer has or has not received

14. NC Department of Health and Human Services DMA Program Integrity False Claims Act 31 U.S.C. §§3729-3733 Imposes liability for person or entity who: Knowingly files a false or fraudulent claim for payments to Medicare, Medicaid, or other federally funded health care program. Knowingly uses false record or statement to obtain payment on a false or fraudulent claim from Medicare, Medicaid or other federally health care program; or Conspires to defraud Medicare, Medicaid or other federally funded health care

15. NC Department of Health and Human Services DMA Program Integrity False Claims Act Medical Assistance Provider False Claims Act (MAPFC) of 1997 makes it unlawful for any Medicaid provider to knowingly make or cause to be made a false claim for payment. Under MAPFC “ “knowingly” means that a provider: Has actual knowledge of the information Acts in deliberate ignorance of the truth or falsity of the information; or Acts in reckless disregard of the truth or falsity of the information. No proof of specific intent to defraud is required.

16. NC Department of Health and Human Services DMA Program Integrity Investigation Program Integrity activity designed to collect facts and make a determination regarding a concern, complaint, or referral on a provider, contractor or beneficiary potentially engaged in FWA

17. NC Department of Health and Human Services DMA Program Integrity Audit Program Integrity activity designed to determine if providers are compliant with rules, regulations, policies, and guidelines

18. NC Department of Health and Human Services DMA Program Integrity Liaisons James Springer: ECBH and CostalCare Mary Bracey: Sandhills Kathy Reid: Eastpointe Elaine Robinson: CenterPoint Ella Peebles: Alliance Behavioral Healthcare Pamela Toney: Back-up

19. NC Department of Health and Human Services DMA Program Integrity Liaisons Monique Loh: MeckLink and Partners Jean Sibbers: Smokey Mountain Center and Western Highlands Network Patrick Piggott: PBH Rodney Ferguson: Back-up

20. NC Department of Health and Human Services DMA Roles & Responsibilities Lead investigations of complaints or leads regarding fraud, waste, or abuse by MCO Conduct a review of all MCO cases referred to DMA regarding potential fraud Resolve complaints in an efficient and timely manner Serve on Interdepartmental Monitoring Teams (Implementation and Monitoring)

21. NC Department of Health and Human Services DMA Roles & Responsibilities Review and approve Compliance Plans Make recommendations regarding MCO PI activities Follow-up on monthly PI reporting activities Participate in monthly MCO PI meetings Participate in Quarterly Statewide PI-MCO meeting to review cases and PI activities

22. NC Department of Health and Human Services DMA Roles & Responsibilities Update MCO on provider good standing status, potential state-wide issues, payment suspension, investigations, etc Educate MCO regarding Program Integrity activities and update on new federal or state laws, rules, regulations.

23. NC Department of Health and Human Services DMA MCO Special Investigations Unit Supervisor Clinical Analyst Investigator Data Analyst

24. NC Department of Health and Human Services DMA MCO Special Investigations Unit Handle all program integrity activities in the MCO Responsible for postpayment reviews in accordance with 42 CFR 456 and prepayment review activities Conduct random reviews of provider contracts and subcontracts Meet with DMA PI and AGO-MID quarterly If there is an allegation of fraud, investigate the allegation by conducting at a minimum, a desk review

25. NC Department of Health and Human Services DMA MCO Investigation Receive complaint or lead Determine if complaint is valid (recipient and provider eligibility) Assign case to an Investigator Review parameters

26. NC Department of Health and Human Services DMA MCO Investigation Develop strategy –Planning meetings & logistics –desk review vs. onsite –announced vs. unannounced –small vs. large sample –Time period –Recipient, staff, complainant, or corporate interviews

27. NC Department of Health and Human Services DMA MCO Investigation Pull population & sample Entrance conference Conduct audit/investigation Exit Conference

28. NC Department of Health and Human Services DMA MCO Investigation Consolidate and summarize findings If extrapolation, use the DMA standard protocol Determine if the case involves potential fraud –Know the definition –Connect the dots

29. NC Department of Health and Human Services DMA MCO Investigation If potential fraud, complete Referral form to DMA with all supporting documentation and information (using best practice standard) If abuse, render MCO administrative sanctions and remember to report on attachment AA. (only recoup once on a specific claim) Attachment AA, Program Integrity activities is due by 5 th of the Month to Program Integrity (Liaison/Chief)

30. NC Department of Health and Human Services DMA DMA Response to MCO Referral Receive cases of potential Fraud from MCO. DMA will conduct a preliminary Review Determine if case warrants a referral to Medicaid Investigation Division. If not an appropriate referral, may request additional documentation or information, or recommend MCO administrative action.

31. NC Department of Health and Human Services DMA DMA Response to MCO Referral The State’s AG’s office, MID and the US Attorney’s Office has the authority to investigate and prosecute Medicaid fraud The lack of knowledge is not a defense for fraud.

32. NC Department of Health and Human Services DMA MCO Referral: Provider Content: Provider name and NPI number The provider’s address The provider type The source of the allegation

33. NC Department of Health and Human Services DMA MCO Referral: Provider Content: The nature of the allegation Description of intentional misconduct The dollar amount paid to the provider over the last three years Copies of all communication between MCO and the provider

34. NC Department of Health and Human Services DMA MCO Referral: Provider Content: Contact information for LME-MCO staff with practical knowledge of the workings of the relevant programs Date reported to the State, and Legal and administrative status of the case

35. NC Department of Health and Human Services DMA MCO Referral: Beneficiary Content: The beneficiary’s name and MID# The Source of the allegation The nature of the allegation Copies of all communication between MCO and recipient/complainant concerning the issue

36. NC Department of Health and Human Services DMA MCO Referral: Beneficiary Content: Contact information for LME-MCO Staff having knowledge of the allegation Date reported to the State, and Legal and administrative status of the case

37. NC Department of Health and Human Services DMA MCO Referral: Send to: Division of Medical Assistance Program Integrity-BIC 2501 Mail Service Center Raleigh, NC 27529-2501 Format: 2 copies and on encrypted/secured CDs/flashdrive Email to: _____@dhhs.nc.gov_____@dhhs.nc.gov (under development)

38. NC Department of Health and Human Services DMA Post-Payment Reviews Determine if provider delivered services that were medically necessary Determine if provider delivered services in compliance with Clinical Coverage policies, guidelines, rules, and regulations Or any other target concern to prevent financial loss to the Medicaid managed care program *Consistent across MCO

39. NC Department of Health and Human Services DMA Sanction Options Termination of provider’s participation Withholding Payments Recoup overpayments Warning Letters for when overpayment is $150 or less Educational letters for provider Suspension of a provider for a period of time Prepayment Claims Review *Consistent across MCO

40. NC Department of Health and Human Services DMA Reporting: Attachment AA Terminations Withholding Payments Recoup overpayments Warning Letters for when overpayment is $150 or less Educational letters for provider Suspension of a provider for a period of time

41. NC Department of Health and Human Services DMA Reporting: Attachment AA Prepayment Claims Review Self Audits (include reasons, effective dates, and $amounts if applicable) Denial of credentials Denial of enrollment Denial of contracts

42. NC Department of Health and Human Services DMA Managed Care Requirements

43. NC Department of Health and Human Services DMA MCO Responsibilities MCO are required to ensure integrity in the Medicaid Managed Care Program and ensure “Services are provided in…the best interest of the Recipients.” Establish clear policies and procedures for the selection and retention of providers Monitor providers regularly to determine compliance

44. NC Department of Health and Human Services DMA MCO Responsibilities Take corrective action if there is failure to comply Develop mechanism to detect both utilization and overutilization of services Develop mechanism to assess the quality and appropriateness of care Ensure providers are credentialed and re-credentialed

45. NC Department of Health and Human Services DMA MCO Responsibilities At a minimum must have administrative and management arrangements or procedures including: Mandatory compliance plan designed to safeguard against fraud and abuse in the Medicaid Managed Care program Written policies and procedures and standards of conduct that articulate the organizations commitment to comply with all federal and state standards

46. NC Department of Health and Human Services DMA MCO Responsibilities Minimum cont. Designate a compliance officer Training & education for the compliance officer and organization employees Lines of communication between compliance officer and the organization employees

47. NC Department of Health and Human Services DMA MCO Responsibilities Minimum cont. Enforcement of standards through well publicized disciplinary guidelines Provisions for internal monitoring and auditing Specifies certain prohibitions aimed at the prevention of fraud and abuse.

48. NC Department of Health and Human Services DMA MCO Responsibilities Must establish safeguards against conflicts of interests on the part of State & local officers and employees and agents of the State who have responsibilities related to the MCO Contract Prohibit affiliations with individuals debarred by Federal agencies and other Federal health care programs –Individuals who are debarred, suspended, or otherwise excluded from participating in procurement activities and non-procurement activities (director, officers, partner, 5% ownership, employee, consultant, or other arrangement) Provisions for prompt responses to detected offenses and the development of corrective action initiatives

49. NC Department of Health and Human Services DMA Compliance

50. NC Department of Health and Human Services DMA Adherence to all applicable statutory, regulatory, & Medicaid Managed Care program requirements (see slide 2)

51. NC Department of Health and Human Services DMA Conduct your self assessment, evaluations and mock reviews to ensure compliance with all rules, regulations, and policies Commitment to ethical and legal business conduct. Responsibility to provide ethical leadership and to ensure that adequate systems are in place to facilitate ethical and legal conduct

52. NC Department of Health and Human Services DMA Establish internal controls and monitor agency conduct to reduce the risk of unlawful or improper activities Requires a substantial commitment of time, energy and resources A cost-effective investment.

53. NC Department of Health and Human Services DMA What happens when things do not go as planned?

54. NC Department of Health and Human Services DMA On-site Investigation

55. NC Department of Health and Human Services DMA Respond to an Investigation Cooperate Comply by producing the documents and information requested Prepare an area for Investigators to conduct the investigation/Audit Entrance Conference, fact finding, and exit conference Administrative Action Findings of an investigation may be referred to the MID, Attorney General’s Office. The State’s MID, AG’s office and the US Attorney’s Office has the authority to investigate and prosecute Medicaid fraud

56. NC Department of Health and Human Services DMA Summary Know Federal and State, rules, regulations, rules, guidelines, and policies Use the PI toolkit to support MCO PI Activities Reporting PI Activities on Attachment AA Managed Care Requirements and Contract

57. NC Department of Health and Human Services DMA Summary Program Integrity Liaisons and contacts Compliance & Risk Investigation of MCO

58. NC Department of Health and Human Services DMA ? QUESTIONS or COMMENTS

59. NC Department of Health and Human Services DMA CONTACT: Patrick O. Piggott, MSW, LCSW, DCSW Chief, Behavioral Health Review Section NC DMA – Program Integrity Phone: (919) 647-8049 Fax: (919) 647-8054 Email: Patrick.Piggott@dhhs.nc.govPatrick.Piggott@dhhs.nc.gov