Self-Audit Power Point - Utah Office of Inspector General
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Self Audits 31 May 2017
Transcript of Self-Audit Power Point - Utah Office of Inspector General
Self Audits
31 May 2017
CAO: 30 May 2017
Toolbox
Self - Audit
Bottom Line Up Front
Self Audits are an important oversight tool in helping to achieve our mission of identifying and reducing fraud, waste and abuse in the Medicaid program. Federal and State OIGs rely upon Self Audits.
They shift internal investigation and recovery to the provider.
It is a great tool that can best be applied to overpayments that do not involve fraud or abuse – focuses on common errors and mistakes.
It helps to identify and correct inappropriate billing practices.
It prevents future losses to the Medicaid program by providing assistance to identifying improper billing practices.
Drives a more efficient Utah OIG through better use of existing resources – maximizing use of taxpayer dollars
through innovation.CAO: 30 May 2017
Outline for Training
• Utah OIG Tools• Why a Self Audit?• How do Self Audits improve outcomes?• Contrasting the Self Audit and the IPPR• Developing a Self Audit Lead• Sample of Google Alert• Audit Processes• Elements of a Self Audit Candidate• Additional Considerations• Other Benefits from a Self Audit• Self Audit Cycle• Self Audit Universe• Self Audit Resources• Questions?
CAO: 30 May 2017
Utah OIG Tools
Self Audits are one of the tools available to Utah OIG to perform oversight duties.
Self Audits include elements of all Oversight Tools.CAO: 30 May 2017
Self Audits Include Elements
of all OIG Oversight Tools
AuditsInvestigationsInspections
Self AuditsEvaluationsPolicy ReviewsUtilization ReviewsTraining
Why a Self Audit?
• Improved use of limited OIG resources:• Freeing up resources
• Opportunity for Provider to see claim through eyes of OIG
• Opportunity for OIG to get direct feedback from Providers:• Policy recommendations, errors, issues• Open dialogue with providers
• Partnership building with Provider community• Friendlier approach to oversight - Partnership
approach
• Saving taxpayer dollars through efficiencies:• Innovation of processes and procedures
CAO: 30 May 2017
How do Self-Audits improve outcomes?
• Reduce fraud and improper payments
• Improve patient care
• Lower the chances of an external audit
• Create a robust culture of compliance
• Improve the program and participation
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Contrasting the Self Auditand the IPPR
Similarities
Differences
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IPPR:• Data pull of paid claims• Manual Review by
Investigator• Findings on Appropriateness
of Claim
Self Audit:• Data pull of paid claims• Manual Review by
Investigator• Findings on Appropriateness
of Claim
IPPR:• Request for Records• Recovery of Already Paid
Claims• Larger Dollar Claims
Self Audit:• Pattern Analysis – Find
Anomalies in Data• Development of Leads• Provider Driven Solution• Educational Tool• Streamlined review
Developing a Self Audit Lead
Identifying potential self audit ideas – Where do the leads (ideas) come from:
• Google Alerts – Medicaid Fraud: • Review other state reporting and news
• Federal OIG Work Plan:• Annual focus based upon trends from Fed OIG
• CMS:• Guidance issued on changes to coverage/payments
• State and federal legislative requests:• Responding to request for information (deceased providers)
• MIB articles outlining changes in billing practices • Past audits and investigations:
• Verifying provider corrective action
Idea is now developed and ready for Self Audit process.
CAO: 30 May 2017
Sample of Google Alert
CAO: 30 May 2017
Elements of a Self Audit Candidate
• Elements of a Good Candidate for Self Audit:1. Smaller Error Amounts:
• Less ROI requires more efficiency2. Less Complex Policy Issues:
• Ease for provider3. Provider Can Benefit:
• Learning opportunity4. Efficiency of Self Audit:
• Better use of resources5. Concurrence:
• Management concurs6. Simple Errors:
• Suspected mistakes only• Simple errors• No suspected fraud or abuse
7. FFS, Waiver or Carve Out:• Not focused on ACO, PMHP• Paid by Medicaid directly
CAO: 30 May 2017
Smaller Potential Recovery
Less Complex Policy Issues
Provider Benefit -Learning Process
Efficiency of Self Audit
Concurrence:
Management
Simple Errors (Not fraud or
abuse)
FFS, Waiver, Carve Out Recipients
Lead
Additional Considerations
Other items to consider in considering a Self Audit:
• Data analysis and pattern development:• Compared to other providers of same community and
patients.• Reimbursement amount in that area compared against the
total amount of reimbursements for that provider over the same period.
• Provider patterns trending up or down?• Ongoing investigations – is a provider, service or action
already being investigated by another group or agency:• Utah OIG Audit or Investigation pending?
• Cost effectiveness/efficiency of resources:• What is the potential recovery?• Best served by Self Audit?
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Other Benefits from a Self-Audit
• Tends to be well received – more welcoming.• Immediate positive impact on program.
• Provider may correct deficiency upon receipt of letter.• Providers’ findings may exceed the scope of the problem
initially identified.• Broader issue uncovered by provider.
• A self audit approach provides an incentive to cooperate with the OIG.
• Development of future leads and ideas.
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Self Audit Cycle
CAO: 30 May 2017
Leads are Developed
Determination that (Provider) is
candidate for Self Audit
Self Audit Lead/Nurse Investigator (Russ Labrum)
reviews data, conducts research
Self Audit letter is prepared, circulated for management, legal and
policy review
Edits are made to Self Audit letter
Self Audit letter is issued
Provider conducts Self Audit, returns completed
form to Utah OIG
Responses are Reviewed
Provider Agrees or Disputes Self Audit
finding
Follow Up, Feedback as Appropriate, Develop New Ideas/Leads
Continuously Innovating
Self Audit Universe
CAO: 30 May 2017
Medicaid Program
Fee-for-Service (FFS)
Carve-Outs Waivers
Prospective Utah OIG Self Audit
Process
Other Medicaid Programs (ACO,
PMHP, Etc.)
Self Audit Resources
• Data Analytic Capabilities Assessment for Medicaid Program Integrity:• https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/data-analytic-assesstoolkit-092214.pdf
• Self-Disclosure Information:• https://oig.hhs.gov/compliance/self-disclosure-info/index.asp
• Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care:• https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-
Prevention/FraudAbuseforProfs/Downloads/GuidelinesAddressingfraudabuseMedMngdCare.pdf
• OIG’s Provider Self-Disclosure Protocol:• https://oig.hhs.gov/compliance/self-disclosure-info/files/Provider-Self-
Disclosure-Protocol.pdf
• HHS OIG Work Plan Archives:• https://www.oig.hhs.gov/reports-and-publications/archives/workplan
CAO: 30 May 2017
Questions?
Gene D. Cottrell, Inspector GeneralUtah Office of Inspector General
Steven L. AnthonyPolicy and Training CoordinatorUtah Office of Inspector General
Nathan Johansen, Deputy Inspector GeneralUtah Office of Inspector General
Russ LabrumNurse Investigator/Self Audit LeadUtah Office of Inspector General
