OIG INITIATIVES FOR 2011 - assets.hcca-info.org · Predictive Modeling Risk Scoring Solution...
Transcript of OIG INITIATIVES FOR 2011 - assets.hcca-info.org · Predictive Modeling Risk Scoring Solution...
4/7/2011
1
Cleveland | Columbus | Indianapolis | Philadelphia | Shanghai | White Plains | Wilmington
www.beneschlaw.com
OIG INITIATIVES FOR 2011
David S. CadeDeputy General Counsel
Department of Health Human Services
Alan E. SchabesPartner
Benesch, Friedlander, Coplan & Aronoff LLP
Fraud Prevention and Detection
2
4/7/2011
2
Antifraud Activity
• Fraud Prevention
o Engaging Medicare Beneficiaries & Stakeholders
o Antifraud Marketing
o Keeping Out Fraudulent Providers and Suppliers
o Avoiding Paying Fraudulent Claims
o Predictive Analytics
o Improving Payment Accuracy
• Fraud Detection
o Coordination with Law Enforcement
o Data Analytics
3
Preventing Medicare Fraud
• Identify high risk providers and claims before
enrollment or payment
• Engage key stakeholders, including physicians
and beneficiaries
4
4/7/2011
3
New Screening and Enrollment Rule
CMS-6028-F
• Provider Screening (ACA § 6401(a))
o Levels of Screening by Categories of Providers:
� Limited – physicians, medical groups, clinics, hospitals
� Moderate – Physical therapists, CMHCs, outpatients rehabs,
ambulance providers, currently enrolled DMEPOS and home
health agencies
� High – Prospective (newly enrolling) home health agencies
and suppliers of DMEPOS; providers and suppliers who have
been reassigned due to a triggering event, such as:
� Excluded by the OIG
� Subject to a payment suspension
� Terminated by Medicaid
� Subject to other final adverse actions
5
New Screening and Enrollment Rule
CMS-6028-F
Final Required Screening and Levels of Risk
TYPE OF SCREENING REQUIRED LIMITED MODERATE HIGH
Verification of any provider/supplier-specific
requirements established by Medicare√√√√ √√√√ √√√√
Conduct license verifications, including licensure
checks across States√√√√ √√√√ √√√√
Database Checks (to verify Social Security
Number (SSN), the National Provider Identifier
(NPI), licensure, an OIG exclusion, taxpayer
identification number, death of individual
practitioner, owner, authorized official, delegated
official, or supervising physician )
√√√√ √√√√ √√√√
Announced or Unannounced Site Visits √√√√ √√√√
Criminal Background Check √√√√
Fingerprinting √√√√
6
4/7/2011
4
New Screening and Enrollment Rule
CMS-6028-F
• Temporary Enrollment Moratorium may be imposed for 6 month increments (ACA § 6401(a))
o Conditions for a temporary moratorium
� CMS data suggests trends associated with high risk of fraud, such
as highly disproportionate number of providers per beneficiary
� A State has imposed a moratorium in a particular geographic
area or on a particular provider/supplier type
� In consultation with the OIG or DOJ, or both
o The moratoria will be limited to:
� Newly enrolling providers
� The establishment of new practice locations, but not the change
of practice location
7
New Screening and Enrollment Rule
CMS-6028-F
• Suspension of payment based on a credible allegation of fraud (ACA § 6402(h))
o Examples of a “credible allegation of fraud” include, but are not
limited to:
� Fraud hotline complaints
� Claims data mining
� Patterns identified through provider audits
� Civil false claims cases
� Law enforcement investigations
� In consultation with the OIG
o Duration of suspension
� For each suspension, attestations would be required every 180 days from the HHS OIG that the payment suspension should remain in place
� The suspension will end after 18 months unless OIG or DOJ
indicated an action was imminent
8
4/7/2011
5
New Screening and Enrollment Rule
CMS-6028-F
• New ACA language at § 1862(o) of the Act provides “[t]he
Secretary may suspend payments to a provider of services or
supplier under this title pending an investigation of a credible
allegation of fraud against the provider of services or supplier,
unless the Secretary determines there is good cause not to
suspend such payments.”
• Statute requires consultation with OIG on whether there’s
“credible allegation of fraud”
• Allegations are considered to be credible when they have
indicia of reliability.
9
New Screening and Enrollment Rule
CMS-6028-F
• Termination of a Provider under Medicaid and CHIP if terminated under Medicare (ACA § 6501)
o Providers who have been terminated under Medicare or another State Medicaid program for cause, or has had its billing privileges after January 1, 2011 must be denied under other State’s Medicaid program or CHIP
o Providers who have been terminated under a State Medicaid
program may be revoked by Medicare
10
4/7/2011
6
Preventing Improper Payments:
Additional provisions from ACA
• Reporting and Returning Overpayments (ACA § 6402
(a))
• Increased Disclosure Requirements (ACA §6401(a))
• Enhanced Oversight(ACA § 6401(a))
o The Secretary shall withhold payment to DMEPOS suppliers
for a period of 90 days after initial enrollment if there is a
significant risk of fraudulent activity
11
The National Fraud Prevention Program
• CMS is currently integrating predictive modeling as
part of an end-to-end solution for detecting and
preventing fraud
• Innovative risk scoring technology will apply a
combination of:
o Behavioral analyses
o Network analyses
o Predictive analyses
• CMS is committed to partnering in the private sector
to develop new innovative technologies
12
4/7/2011
7
National Fraud Prevention Program
DevelopTestRefine
Predictive Modeling
Risk Scoring Solution
Including:ClaimsEnrollment RecordsInvestigationsComplaintsStolen IDs
Alert Management System
Program Integrity Contractors
Data
13
National Fraud Prevention Program
Implementing the Risk Scoring Solution into Claims Processing
Risk Scoring Solution
11
Medicare Administrative
Contractor, Shared Systems
22
Common Working File -Consolidated
Data
Edits
33
445566
14
4/7/2011
8
Detecting Medicare Fraud
• Coordination with law enforcement
• Improving communications with key
stakeholders
15
Field Office Initiatives
• CMS has Program Integrity Staff in Field Offices in:o Miami, Chicago, Dallas, Atlanta, New York and San Francisco
• Field staff work very closely with local law
enforcement and contractors. Some examples
include:o The FO in Miami has been key in implementing Medicare’s Florida
Fraud Hotline (1-866-417-2078) for beneficiaries to report suspect
services. The hotline allows investigators to respond to beneficiary
tips immediately and often to stop paying fraudulent providers
which has resulted in millions of dollars in savings.
o The New York FO has actively participated in the Identity Theft
Town Hall meetings have been coordinated with Representative
Steve Israel and the FBI Cyber Crimes Unit, IRS, SSA,
and Nassau County DA's Office.
16
4/7/2011
9
Health Care Fraud Prevention and
Enforcement Action Team (HEAT)
• The Health Care Fraud Prevention and Enforcement Action
Team (HEAT) is a joint Cabinet-level effort established by the
President and led by Secretary Sebelius and Attorney General
Holder. A major part of the HEAT initiative is the use of a criminal
Strike Force. The HEAT Strike Force, which now operates in nine
cities – Miami, Los Angeles, Detroit, Houston, Brooklyn, Tampa,
Baton Rouge, Dallas, and Chicago.
• The Strike Force investigates and tracks down individuals and
entities defrauding Medicare and other government health
care programs and pursues them criminally. Strike Force
prosecutions are “data driven,” target individuals and groups
actively involved in ongoing fraud schemes, and seek speedy
investigations, pleas, and/or criminal convictions.
17
OIG Initiatives for 2011
18
4/7/2011
10
OIG Initiatives for 2011
• On October 7, 2010, the Department of Health and Human
Services, Office of Inspector General (OIG) released its 2011
Work Plan.
• Some of the enforcement priorities defined in the 2011 Plan are
based on statutory mandates to target particular areas, while
others reflect the OIG’s assessment of “relative risk” in the
Medicare and Medicaid programs
• The Work Plan sets forth OIG initiatives and priorities for 2011.
Initiatives include audits, investigations, inspections, industry
guidance and enforcement actions including, but not limited
to, civil monetary penalties, assessments and exclusions.
19
OIG Initiatives for 2011
• The 2011 Work Plan’s array of initiatives suggests that the OIG will focus its efforts on:
o Ensuring compliance with certain highly technical billing and reimbursement requirements
o Analyzing whether services are being provided at substandard levels of quality and with insufficient levels of documentation
o Addressing compliance with some of the electronic health record provisions adopted in the 2009 Recovery and Reinvestment Act
o Implementing various program integrity standards enacted under the 2010 Affordable Care Act
20
4/7/2011
11
OIG Initiatives for 2011
• The OIG Work Plan will affect all post-acute care providers including nursing homes, home health agencies, hospices, rehabilitation hospitals and durable medical equipment providers. The Work Plan makes clear that the OIG is continuing its focus on particular types of providers who are perceived to pose heightened risks of fraud
and abuse.
21
Key Nursing Home Initiatives
22
4/7/2011
12
Key Nursing Home Initiatives
• Medicare Quality of Care
o Review the quality of care provided in Medicare SNFs to
determine the extent to which SNFs have
� Developed plans of care based on assessments of
beneficiaries
� Provided services to beneficiaries in accordance with the
plans of care
� Planned for beneficiaries’ discharges
o Increased numbers of False Claim Act cases
� Worthless services vs. bad survey case – need to
determine where is the line
� Express/implied certification
23
Key Nursing Home Initiatives
• Nursing Facility Ownership and Transparency
OIG has expressed concern that complex ownership structures make it difficult to determine which entity is legally liable for patient care and, as a result, the OIG is initiating heightened scrutiny of investor owned, Medicaid certified nursing facilities
24
4/7/2011
13
Nursing Home Transparency(PPACA, §§6101-21)
• Mandated disclosure and public availability of information on ownership, management, and organizational structures of Medicare SNFs and Medicaid NFs (final regulations must be issued by March, 2012). PPACA, §6101
o Effective immediately, SNFs and NFs must maintain information regarding ownership, identity of directors and officers and secured lenders and mortgagees
� Facilities are currently required to disclose information on individuals and entities that have a direct or indirect ownership of 5% or more and officers, directors, and partners and holders of the mortgages, deeds of trusts, notes or other obligations secured by the facilities or property of the facilities
Nursing Home Transparency
• Disclosure includes name, title, and period of service for officers, directors, members, managers, partners, trustees, or managing employees of facility
• Managing employee is defined as an individual who directly or indirectly manages, advises, or supervises any element of the practices, finances, or operations of the facility
• “Additional disclosable party” covers those who exercise operational, financial, or managerial control over the facility orown property of the facility or lease or sublease real property to it or provide management/administrative services, management or clinical consulting services or accounting financial services
4/7/2011
14
Nursing Home Transparency
• By July, 2012, a nursing facility must report the required information on a standardized form to HHS. At that time, a nursing facility will also have to certify, as a condition of program participation, that the information provided is, to the best of its knowledge, accurate and current
• By March, 2013, HHS will make the ownership and additional disclosable party information submitted on the standardized form available to the public
Nursing Home Transparency
• If a nursing facility also reports any of this information to the Internal Revenue Service (for example, on a Form 990), the SEC or HHS (on a Form 855A), the nursing facility can submit any of these forms to satisfy the current requirement
• The disclosure of additional disclosable parties may increase the risk level for these parties and, directly or indirectly, affect professional liability exposure
4/7/2011
15
Nursing Home Transparency
• Required establishment and operation of an effective compliance and ethics program(final regulations must be issued by March, 2012; programs to be operative by first day of first calendar quarter one year after final regulations). PPACA, §6102
• SNFs and NFs will be required to have mandatory operational compliance and ethics programs within 36 months of enactment
Nursing Home Transparency
• Compliance plan must be effective in preventing and detecting criminal, civil, and administrative violations in promoting quality care
• Secretary’s regulations may include a model compliance plan
4/7/2011
16
Nursing Home Transparency
• Not later than three years after the date of the promulgation of the regulations, the HHS Secretary must complete an evaluation of the compliance and ethics programs established under this law. The evaluation must determine if the programs led to (i) changes in deficiency citations; (ii) changes in quality performance; or (iii) changes in other metrics of patient quality of care. A report on this evaluation must be submitted to Congress and must include recommendations regarding changes in the requirements for the programs that the Secretary deems appropriate
Nursing Home Transparency
• Quality assurance and performance improvement program – HHS Secretary to establish by December 31, 2011, with facilities submitting their plans within one year of final regulations. PPACA, §6102
• Review, modification, and improvement of Nursing Home Compare Medicare websiteusing newly required information (generally effective one year after enactment). PPACA, §6103
4/7/2011
17
Nursing Home Transparency
• On March 18, 2011, CMS issued Survey and Certification Letter (S&C 11-17-NH)
• CMS announced three implementation stepso On 4/23/11, the Nursing Home Compare website
will provide the ability to file complaints online and provide a standardized complaint form
o On 4/23/11, the website will contain additional information regarding the rights of nursing home residents and the ability to enforce them
o On 7/23/11, the website will set forth information on civil monetary penalties and complaints lodged against facilities
Nursing Home Transparency
• New Nursing Home CMP Final Rule
(March 18, 2011) – Use of Independent
Informal Dispute Resolution, Escrow of
Assessed CMPs and limitations on 50%
Reduction on Settlement
4/7/2011
18
Key Nursing Home Initiatives
• Poorly Performing Facilities
o Review enforcement measures implemented by both CMS and State SSA for poorly performing nursing homes
o Review enforcement decisions resulting from survey and certification inspections and follow-up measures to ensure plan of correction implementation
• Resident Hospitalization
o Review resident hospitalizations to determine if hospitalization during a SNF stay was caused by poor quality of care of unnecessary fragmentation of services
o Identification of nursing home “never events”
• Assessment and Monitoring of Nursing Home Residents Receiving Atypical Antipsychotic Drugs
o Reviews of care plans and assessments as the relate to the use of atypical antipsychotic drugs
o Evaluate the extent to which SNFs use CMS’s Resident Assessment Protocol (RAP) for psychotropic drugs to develop residents’ care plans
35
Key Nursing Home Initiatives
• RUGs Accuracy
o Review Medicare payments to SNFs to determine whether the Resource Utilization Group (RUG) categories are supported by the patient’s medical records
o Increased analysis of accuracy of Minimum Data Set (MDS) data
• Medicaid Quality of Care Incentive Payments
o Review Medicaid incentive payments to nursing facilities based on the facilities’ quality of care performance measures
• Employee Criminal Background Checks
36
4/7/2011
19
Key Nursing Home Initiatives
• Review whether nursing facilities have employed
individuals who have criminal convictions
• Part B Services During Non-Part A Covered Stays
o Review claims from 2008 for Part B services
provided to nursing home residents whose stays
are not paid for under Medicare’s Part A SNF
benefit
• Hospice Services in SNFs
o Review hospice utilization in nursing facilities to
determine whether hospice beneficiaries met
Medicare coverage requirements
37
Key Nursing Home Initiatives
o Review business relationships between nursing facilities and hospice providers
� Coordination of care between SNF and hospice provider
� Identify service and payment arrangements between SNF and hospice provider
o Assess the marketing practices and materials of
hospice providers associated with high utilization
patterns
• Disaster Preparedness
o Review SNFs emergency preparedness plans to
ensure they are adequate
38
4/7/2011
20
Key Home Health Care Initiatives
39
Key Home Health Care Initiatives
• Part B Payments to Home Health Beneficiarieso Are HHA’s billing for services and medical supplies
outside of the prospective payment?• Claims for Home Health Resource Groups• Oversight of outcome and Assessment Information Set
(OASIS) Data• HHA Profitability Review• Mandated face-to-face encounters with patients before
physicians certify Medicare eligibility for home health services and durable medical equipment (PPACA, §6407). But, physicians include nurse practitioners, clinical nurse specialists, certified nurse mid-wives (home health only), and physician assistants working with physicians (PPACA, §§6407 and 10605)
40
4/7/2011
21
OTHER KEY INITIATIVES
41
Other Key Initiatives
• 60-Day Period For Reporting and Returning Detected Overpayments (PPACA §6402(a))
• Medicare Part B Payment for Home Blood Glucose Testing Supplies
• Medicare Payments for Power Wheelchair Supplies
42
4/7/2011
22
Other Key Initiatives
• Frequency of Replacement of Supplies for Durable Medical Equipment
o Review compliance of DMEPOS suppliers with Medicare requirements for frequently replaced supplies
� Determine whether suppliers automatically CPAP and respiratory-assist device supplies without first obtaining a physician order
• Medicaid Medical Equipment
o Review Medicaid payments for medical supplies and equipment to determine whether:
� They were properly authorized by physicians
� Products were received by beneficiaries
� Amounts paid were within Medicaid payment guidelines
43
Other Key Initiatives
• Medicare Pricing for Parenteral Nutrition
o Review of the Medicare fee schedule for parenteral nutrition compared with fees paid by other payor sources
• Rehabilitative Services
o Review Medicaid claims for rehabilitative services to determine whether the services were provided in accordance with federal and state guidelines
• Medicaid Hospice Services
o Review Medicaid payments for hospice services to determine whether the services were provided in accordance with federal and state reimbursement requirements and were reasonable and necessary
• Medicaid Adult Day Care Services
o Review Medicaid payments to providers of adult day care services to determine whether the payments were in compliance with federal and state requirements
44
4/7/2011
23
OIG INITIATIVES FOR 2011
Questions?
45
6580514_1