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Arkansas Medicaid Provider Annual Billing Workshop Elizabeth Smith - - PowerPoint PPT Presentation
Arkansas Medicaid Provider Annual Billing Workshop Elizabeth Smith - - PowerPoint PPT Presentation
Arkansas Medicaid Provider Annual Billing Workshop Elizabeth Smith Inspector General Mission of OMIG: To detect and prevent fraud, waste, and abuse within the medical assistance program. Medicaid Auditors OMIG (Office of Medicaid
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Medicaid Auditors
- OMIG (Office of Medicaid Inspector General)
- Legislative Audit
- DHS (Retrospective Review)
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OMIG’s 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 the Medicaid program.
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Prevent waste in the program
- Identify policies needing revision
- Implement changes to Medicaid programs
- Medicaid worker identification number
- Impact of EVV legislation
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OMIG Audit Process
Who do you audit?
- New Providers
- Previously Audited Providers
- Providers Identified through Data Analytics
- Providers Identified by Complaint
- Previously Unidentified Providers
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OMIG Audit Process
Why do you audit?
- Fraud Hotline Complaints/Tips
- Law Enforcement Referrals
- Internal Referrals
- Corrective Action Plan Compliance Reviews
- Data Analytics
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OMIG Data Analytics
OPTUM – Fraud Detection System
- Provider Spike Detection
- Peer Review Analysis and Outlier Identification
- Algorithms
- Claims Risk Analysis
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OMIG Audit Process
Field Audit
- On-site Review
- Conduct 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
- Identical to field audits
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Records Request
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
Potential Outcomes
- No findings
- Findings
- recoupment
- Observations
- Non-monetary
- Area of Concern
- MFCU/Law Enforcement Referral
- Credible allegation of fraud-requires temporary
suspension; Possible suspension of performer only
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Corrective Action Plans
Website steps
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Self-Reporting & Self-Disclosure
Duty of the Medicaid Inspector General is to:
- 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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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
- Provide a person/name/position for
accountability
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