Arkansas Medicaid Provider Annual Billing Workshop · • Reversing claims-Creates uncertainty...
Transcript of Arkansas Medicaid Provider Annual Billing Workshop · • Reversing claims-Creates uncertainty...
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Arkansas Medicaid Provider Annual Billing Workshop
Elizabeth SmithInspector General
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Mission of OMIG:
To detect and prevent fraud, waste, and abuse within the medical assistance program.
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Medicaid Auditors• OMIG (Office of Medicaid Inspector General)• Legislative Audit• DHS (Retrospective Review)
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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.
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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 ProcessWho 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 ProcessWhy 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 AnalyticsOPTUM – Fraud Detection System• Provider Spike Detection • Peer Review Analysis and Outlier Identification• Algorithms • Claims Risk Analysis
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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
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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
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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
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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
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Corrective Action Plans
Websitesteps
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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
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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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Reagan Cook, RN, CPC, CPMA, CPIPRegistered Nurse Manager323 Center Street, Ste. 1200Little Rock, AR [email protected]