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BRANDY COOK PROGRAM ADMINISTRATOR OFFICE OF THE MEDICAID INSPECTOR GENERAL
Ark Arkans nsas Me Medi dicaid d Provide der r Annua Annual - - PowerPoint PPT Presentation
Ark Arkans nsas Me Medi dicaid d Provide der r Annua Annual - - PowerPoint PPT Presentation
Ark Arkans nsas Me Medi dicaid d Provide der r Annua Annual Billing ng Work rksho hop BRANDY COOK PROGRAM ADMINISTRATOR OFFICE OF THE MEDICAID INSPECTOR GENERAL Mission of OMIG: To detect and prevent fraud, waste, and abuse within
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Medicaid Auditors
- OMIG (Office of Medicaid Inspector General)
- Legislative Audit
- DHS (Retrospective Review)
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OMIG Requirements
Program Integrity - To prevent, detect, and investigate fraud, waste, and abuse in the Medicaid Program. Verify whether services reimbursed by Medicaid were properly billed and actually furnished to beneficiaries; Recover improperly expended funds; Report fraud and abuse to US HHS; Refer cases to AG MFCU & law enforcement for criminal prosecution; Recommend and implement changes in Medicaid
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Prevent Waste
- Identify policies needing revision
- Implement changes to Medicaid programs
- Medicaid worker identification number
- Impact of EVV legislation
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OMIG Audit Selection Criteria
- Providers Identified by Data Analytics = 86%
- Fraud Hotline Complaints/Tips
- Law Enforcement Referrals
- Internal Referrals
- Corrective Action Plan - Compliance Reviews
- New Providers
- Previously Unidentified Providers
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OMIG Data Analytics
OPTUM – Fraud Detection System
- Provider Spike Detection
- Peer Review Analysis & Outlier Identification
- Algorithms
- Claims Risk Analysis
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Request for Records
Authority as Program Integrity Function
- Arkansas Medicaid Manual
- §142.300 - Conditions Related to Record Keeping
- MAINTAIN YOUR RECORDS!!!
- Enrollment Contract requirement
- §151.000 - Grounds for Sanctioning Providers
Subpoena Power and Production of Records
- Ark. Code Ann. §20-77-2506
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OMIG Audit Process
Field Audit
- On-site Review
- Staff and Management Interviews
- Audit Scope:
- OMIG may review claims that are 3
years old
- OMIG may review claims that are 5
years old if fraud is suspected
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OMIG Audit Process
Desk Audit
- Off-site Review
- OMIG requests records from the provider
- The provider must respond to a records
request within 14 calendar days
- Audit Scope
- 3 years
- 5 years if fraud suspected
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OMIG Audit Process
Potential Outcomes
- No findings
- Area of Concern
- Observations - Non-monetary
- Findings – repayment
- MFCU/Law Enforcement Referral
Credible allegation of fraud-requires temporary suspension; Possible suspension of performer
- nly
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OMIG duties regarding Self-Reporting & Self-Disclosure
- Develop protocols for efficient self-disclosure
- Consider a Medicaid Provider’s good faith as
a mitigating factor
- Self-Disclosure Protocol on OMIG website
- OMIG.Arkansas.gov
- Reversing claims-Creates uncertainty
regarding questioned claims
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Provider duties regarding Corrective Action Plans
- Read the OMIG Report / Findings
- Develop a plan of action addressing
findings, observations, and areas of concern
- Be specific in your steps and procedure
including dates of implementation and completion
- Provide a person/name/position for
accountability
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Corrective Action Plans
Website steps
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QUESTIONS??
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CONTACT INFORMATION
Brandy Cook, CPC Program Administrator 323 Center Street, Ste. 1200 Little Rock, AR 72201 501.537.2281 brandy.cook@omig.arkansas.gov