OIG/ HHS and State Sponsored Medicaid Audits Target: : Behaviora - - PowerPoint PPT Presentation
Lesson ons Learned: OIG/ HHS and State Sponsored Medicaid Audits Target: : Behaviora oral Health Services July 15, 2014 Prepared for the Council by Susan Dess, RN, MS Crestline Advisors 1 2 Purpose Recent Federal OIG BH Audits
Lesson
Target:
: Behaviora
July 15, 2014 Prepared for the Council by Susan Dess, RN, MS Crestline Advisors
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Purpose Recent Federal OIG BH Audits – NJ, WI, NY, MO, State-Sponsored Audits- CA, NM Recovery Audits AZ Specifics CMS Regulations, Expectations, etc. Audit processes Regulatory Changes Compliance Best Practices Medical Necessity Implications to Arizona Providers and Readiness Additional Information Questions
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Target Audits: Medicaid
nable e billing for OP mental health h servi vices es
Target Audit: Medicare
http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf
Audit A-02-12-01009/released 12-24-13
Major Finding/CMS Recommendation
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Audit A-05-07-00036 / released 9-11-13
payments did not comply with Federal requirements
unallowable
Major Findings/CMS Recommendation
workers and social workers that could be claimed as "other services" under the State's Medicaid Early and Periodic Screening, Diagnostic, and Treatment program, known as HealthCheck.
RCC costs claimed under HealthCheck
for claiming allowable Medicaid RCC costs under HealthCheck
http://oig.hhs.gov/oas/reports/region5/50700036.pdf
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Audit A-02-11-01038 / released 9/5/13
based providers were not in accordance with Federal and State requirements.
discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy, among others.
▶ Major Findings/ CMS Recommendation
and State requirements
adequately monitored the CDT program, monitoring required
http://oig.hhs.gov/oas/reports/region2/21101038.asp
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Audit A-05-12-00050 / released 6/21/13
inpatient psychiatric service and disproportionate share hospital (DSH) payments made to Hawthorn Children's Psychiatric Hospital (Hawthorn) for claims with dates of service, July 1, 2005, through June 30, 2010 was not claimed in accordance with Federal requirements for inpatient psychiatric hospital services
▶ Major Findings/CMS Recommendations
Conditions of Participation (CoP) applicable to psychiatric hospitals and Hawthorn did not demonstrate compliance with the special Medicare CoP during the audit period
Hawthorn for claims with dates of service after the audit period
http://oig.hhs.gov/oas/reports/region5/51200050.asp 11
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July 2013 - DHCS Audits and Investigation
August 2013 - Medicaid Payments to 46
Result -16 clinics referred to DOJ
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Medi-Cal launching an overhaul of its drug rehabilitation
The Department of Health Care Services pledged a
The department also will ask the federal government for
The report made public an internal audit that identified
http://cironline.org/reports/medi-cal-agency-overhaul-drug-rehab-program-after-critical-audit-5777
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Public Consulting Group (PCG) audits ensued CMS was notified of results Medicaid funds for 15 BH agencies were
15 agencies referred to NM Attorney General 13 Agencies were transitioned to 5 AZ BH
2 Agencies were fined and given technical
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Under the Affordable Care Act (ACA), states
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Clinical Case File Audit
IT/Billing Systems Audit
Enterprise Audits
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Average error rate of 57.1% for 15 high
Significant levels of non-compliance with
Poor documentation practices Lack of safeguards against overbilling Deficiencies in accuracy of clinical
Quality of Care concerns
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Software company prevented reviewers from
Lack of audit trail for the creation of and
Lack of audit trail for any changes made to
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Poor Quality Management Lack of identified Compliance Officer Compliance Officer not reporting to BOD Lack of compliance oversight by BOD Billing code selection or direction by billing
Duplicative billing of funding streams Conflicts of Interest not identified by BOD
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Cross billing at different locations at same time Cross billing multiple codes and double billing (individual
Uncertainty as to who rendered services Billed units did not match units documented on progress
Copying and pasting of progress notes Up-coding of individual therapy Excessive billing for psychosocial rehab Forging clinical records to incorporate more time than truly
Billing of OP services the same day as bundled services
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Assessments were not up to date (within last 12 months) Incomplete critical information such as diagnosis Substance abuse history missing for persons with dual
Treatment plans were not up-to-date or individualized Goals were not measureable and service-specific clinical
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57808 Federal Register/Vol. 76, No. 180/
Centers for Medicare & Medicaid Services
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http://www.medicaid-rac.com/medicaid-rac-activity/ Click on the state
The state is seeking exemptions from RAC audit scope The AHCCCS has a contract with Recovery Audit Specialists (RAS),
which provides services that include detection, confirmation, and collection of overpayments. RAS reports audit findings at regularly agreed upon intervals and recommends corrective action.
At the current time, the state-wide contract with RAS does not
address identification of underpayments, however the state will be working to address the inclusion of activities related to underpayments in the future.
The state has designated Recovery Audit Specialists, LLC as its RAC
contractor through its existing state-wide cost recovery contract (December 2010)
On 3/4/2013, the state issued an RFP for both RAC and Third Party
Liability services; proposals were due 4/15/2013
In July 2013, the state awarded a contract to HMS to perform RAC
services
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RACs keep about 12% of receivables In the final RAC rule CMS estimated that
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Year 2012 2012 2013 2013 2014 2014 2015 2015 2016 2016 TOTAL Total Expected Collection $110 M $330 M $ 480 M $580 $580 $630 $630 $2.13 B Actual Collection $4.2 B
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Understanding of CMS definitions as
Grasp of the seven elements of compliance
Provision of medically necessary services Application of best practices Evaluation of effectiveness
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Specific provisions must be included in policies and
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Compliance and FWA Training and education
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Lines of communication must allow for confidential,
Well publicized disciplinary standards that articulate
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Routine internal monitoring, auditing and identification
Oversight, monitoring and auditing of FDRs Evaluation of overall effectiveness of the compliance
Timely, reasonable inquiries into misconduct Appropriate corrective actions Procedures for voluntary self-reporting of potential
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Meet frequently with managers and attend
Observe operations personnel in their job
Survey employees about attitudes towards
Celebrate compliance achievements and
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Compliance Expertise on Board/Audit or
Board agenda includes compliance as
Board minutes document detailed discussion
Board regularly educated on and acts upon
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Compliance issues analyzed to identify trends Incentives for compliance, and disciplinary
Centralized oversight over contracted
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Was the proper reporting structure in place to receive ad
Was there a prompt response to the issue? Was the issue resolved (including corrective action plan)? Were necessary systemic changes implemented to ensure
Was monitoring and auditing performed to ensure
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Compliance reports not provided regularly to the
Little oversight over FDRs (no monitoring/auditing) No confidential/anonymous reporting Employees afraid to report compliance issues Little monitoring of operations; no or infrequent audits Responds to incident but no systemic fix Discipline inadequate / inconsistent Allegations of non-compliance not effectively investigated No systematic/overt efforts by senior leadership to build a
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Diagnosis of a mental, behavioral, or emotional disorder
Disorder is current and diagnosed in the past year Disorder results in functional impairment which
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The Affordable Care Act and Medicaid “Balancing Incentives”
Routine review of relatively quickly reliable, valid criteria for
The GAF is “useful in planning treatment and measuring its
In addition, the GAF scale “may be particularly useful in
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Medic
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Use a standardized documentation system to support documentation of medical necessity. The following provides an example:
assessed needs
needs
numbered treatment recommendations/assessed needs
frequency, duration and/or responsible type of provider
goal(s)/objective(s) and identified client response and outcomes/ progress towards goal(s)/objective(s)
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Develop an understanding of Medicaid and
Be aware of CMS expectations for
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Each provider organization should conduct a review of:
Enterprise functions:
IT System
Clinical practices
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AHCCCS Office of the Inspector General
Recovery Audit Specialists, LLC., is the state-
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Links to CMS information
ityFinal%209-4-07.pdf
resource-material.asp
Topics/Program-Integrity/Program-Integrity.html
Prevention/MedicaidIntegrityProgram/Downloads/Medicaid_RAC_FAQ.pdf
Link to national and local compliance conferences
auditcomp-brochure.pdf
Links to supporting documents and presentations
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Susan@CrestlineAdvisors.Com 602-502-0849 www.crestlineadvisors.com
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