Arkansas Medicaid Provider Annual Billing Workshop · • Reversing claims-Creates uncertainty...
Transcript of Arkansas Medicaid Provider Annual Billing Workshop · • Reversing claims-Creates uncertainty...
Arkansas Medicaid Provider Annual Billing Workshop
Elizabeth SmithInspector General
Mission of OMIG:
To detect and prevent fraud, waste, and abuse within the medical assistance program.
Medicaid Auditors• OMIG (Office of Medicaid Inspector General)• Legislative Audit• DHS (Retrospective Review)
OMIG’s RequirementsProgram 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.
Prevent waste in the program• Identify policies needing revision• Implement changes to Medicaid programs• Medicaid worker identification number• Impact of EVV legislation
OMIG Audit ProcessWho do you audit?• New Providers• Previously Audited Providers• Providers Identified through Data Analytics• Providers Identified by Complaint• Previously Unidentified Providers
OMIG Audit ProcessWhy do you audit?• Fraud Hotline Complaints/Tips• Law Enforcement Referrals• Internal Referrals• Corrective Action Plan Compliance Reviews• Data Analytics
OMIG Data AnalyticsOPTUM – Fraud Detection System• Provider Spike Detection • Peer Review Analysis and Outlier Identification• Algorithms • Claims Risk Analysis
OMIG Audit ProcessField 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
OMIG Audit ProcessDesk 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
Records RequestAuthority 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
OMIG Audit ProcessPotential 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
Corrective Action Plans
Websitesteps
Self-Reporting & Self-DisclosureDuty 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
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
Reagan Cook, RN, CPC, CPMA, CPIPRegistered Nurse Manager323 Center Street, Ste. 1200Little Rock, AR [email protected]