Utah Medicaid Audits: 2008 - 2010 · Office of the Legislative Auditor General Slide 7 Prior...
Transcript of Utah Medicaid Audits: 2008 - 2010 · Office of the Legislative Auditor General Slide 7 Prior...
Utah Medicaid Audits:
2008 - 2010
Office of the Utah Legislative
Auditor General
NLPES Fall Conference
2011
Slide 2
Office of the Utah Legislative Auditor General
Medicaid Audits 2008 - 2010
Medicaid Audits:
Fraud, Waste, and Abuse Controls in Utah’s
Medicaid Program
Utah Medicaid Managed Care
Utah Medicaid Provider Cost Control
Medicaid’s Implementation of Audit
Recommendations
Office of the Legislative Auditor General
A Performance Audit of
Fraud, Waste, and Abuse Controls in
Utah’s Medicaid Program
Utah Legislative Auditor General
August 2009
Slide 4
Fraud, Waste, and Abuse Controls
Audit Reviewed Controls to:
– Prevent
– Detect
– Collect
Fraud, Waste, and Abuse
– Small Percent Of Providers Involved
– Estimated Conservatively at 3 Percent Of Claims
– At 3 percent, Utah Could Recover An Additional
$20.2 Million
Office of the Legislative Auditor General
Slide 5
Cost Savings Model for BPI
Office of the Legislative Auditor General Slide 5
FOR MORE INFORMATION
See Chapter I, Page 2
Ch. II
Improve Controls
Over Utilization
Ch. III
Improve Controls
Over Provider
Enrollment
Ch. IV
Improve
Effectiveness and
Efficiency of Cost
Recovery Effort
Ch. V
Improve Oversight
and Ensure All
Medicaid Funds
Are Reviewed
Cost
Avoidance
Cost
Recovery
Slide 6Office of the Legislative Auditor General Slide 6
Ch. II
Improve Controls
Over Utilization
Ch. III
Improve Controls
Over Provider
Enrollment
Ch. IV
Improve
Effectiveness and
Efficiency of Cost
Recovery Effort
Ch. V
Improve Oversight
and Ensure All
Medicaid Funds
Are Reviewed
Cost
Avoidance
Cost
Recovery
Slide 7Office of the Legislative Auditor General
Prior Authorization Is Not
Adequately Controlling Utilization
Unclear Policies Can Lead to Unnecessary Medical Costs
– Circumcisions
– Mid-face reconstruction
– Graft of Ear or Nose
– Rhinoplasty
– Breast Augmentation
FOR MORE INFORMATION
See Chapter II, Figure 2.3, Page 18
Slide 8
Insufficient Management Control Has
Led to Unnecessary Medical Costs
Office of the Legislative Auditor General Slide 8
FOR MORE INFORMATION
See Chapter II, Figure 2.7 Page 24
Nurse Approval Percent Average Monthly
Requests
Nurse O 92.2% 179
Nurse F 91.4% 174
Nurse G 48.4% 153
Nurses Approval Rate For Same Procedures
Slide 9
Prior Authorization Cost Savings
For Physician Costs
Office of the Legislative Auditor General Slide 9
FOR MORE INFORMATION
See Chapter II, Figure 2.8, Page 27
Approval Rate Estimated Cost Savings Difference From Actual
CY 2008 Cost Savings
75% $18,300,000 $9,500,000
79% $15,400,000 $6,600,000
83% $12,500,000 $3,700,000
88% $8,800,000 0
93% $5,100,000 ($3,700,000)
97% $2,200,000 ($6,600,000)
100% $0 ($8,800,000)
Slide 10Office of the Legislative Auditor General Slide 10
Ch. II
Improve Controls
Over Utilization
Ch. III
Improve Controls
Over Provider
Enrollment
Ch. IV
Improve
Effectiveness and
Efficiency of Cost
Recovery Effort
Ch. V
Improve Oversight
and Ensure All
Medicaid Funds
Are Reviewed
Cost
Avoidance
Cost
Recovery
Slide 11Office of the Legislative Auditor General
Controls Over Enrolling New
Providers Can Be Strengthened
Reviewing Providers That Exhibit Signs
of Fraud Leads To Cost Avoidance
Medicaid Does Not Deny Any Providers
Other States/Insurance Companies Have
Stricter Acceptance Policies
FOR MORE INFORMATION
See Chapter III, Pages 30 to 34
Slide 12Office of the Legislative Auditor General
Monitoring of Current
Providers Can Improve
127 Current Medicaid Providers Have
DOPL Disciplines:
– Sexual Conduct With Patient While Under
Nitrous-Oxide
– Filing False Insurance Claims
– Communications Fraud
– Unwarranted Medical Procedures
See Chapter IV, Pages 34 to 38
FOR MORE INFORMATION
Slide 13Office of the Legislative Auditor General Slide 13
Ch. II
Improve Controls
Over Utilization
Ch. III
Improve Controls
Over Provider
Enrollment
Ch. IV
Improve
Effectiveness and
Efficiency of Cost
Recovery Effort
Ch. V
Improve Oversight
and Ensure All
Medicaid Funds
Are Reviewed
Cost
Avoidance
Cost
Recovery
Slide 14
Inefficiency and Ineffectiveness is Hampering Cost
Recovery Efforts
Office of the Legislative Auditor General Slide 14
FOR MORE INFORMATION
See Chapter IV, Figure 4.1, Page 44
Increased Recovery
From 1.72 Percent
Increased Savings
Federal and State
Increased Savings
State Only
2.00% $4.4 Million $1.3 Million
2.50% $12.3 Million $3.5 Million
2.75% $16.2 Million $4.7 Million
3.00% $20.2 Million $5.8 Million
3.50% $28.1 Million $8 Million
4.00% $36 Million $10.3 Million
5.00% $51.7 Million $14.9 Million
Slide 15Office of the Legislative Auditor General
Problems Hindering Fraud and
Abuse Recoveries
Ineffective Analytical Tool
– 62% of Provider Types Receive No
Electronic Review
Unreliable Data
– Inaccurate Recovery Data
FOR MORE INFORMATION
See Chapter IV, Pages 44 to 52
Slide 16Office of the Legislative Auditor General Slide 16
FOR MORE INFORMATION
See Chapter IV, Figure 4.7, Page 53
Follow-Up
Reviews
Inpatient
Hospital
Salary/Benefits $63,730 $112,367
Recoveries $16,346 $588,632
Recovery Per
$1.00 Expenditure$.26 $5.24
Net or Benefit Cost ($47,384) $476,265
Rates of Return for Two Primary BPI Activities
Inefficient Use of Staff Time
Slide 17Office of the Legislative Auditor General Slide 17
Ch. II
Improve Controls
Over Utilization
Ch. III
Improve Controls
Over Provider
Enrollment
Ch. IV
Improve
Effectiveness and
Efficiency of Cost
Recovery Effort
Ch. V
Improve Oversight
and Ensure All
Medicaid Funds
Are Reviewed
Cost
Avoidance
Cost
Recovery
Slide 18Office of the Legislative Auditor General
95% of Medicaid Funds Not
Being Reviewed by BPI
78% of Hospital Claims Not Being
Reviewed
Over 90% of Non-Inpatient Claims Not
Being Reviewed
No Oversight of Other Contracted
Medicaid Services
FOR MORE INFORMATION
See Chapter V, Pages 57 to 69
Slide 19Office of the Legislative Auditor General
Greater Oversight Needed
FOR MORE INFORMATION
See Chapter VI, Pages 71 to 81
Office of the Legislative Auditor General Slide 19
Bureau of Program Integrity – BPI
DOH Internal Auditors
Medicaid Auditors
Utah Medicaid Managed Care
Utah Legislative Auditor General
August 2009
Slide 21Office of the Legislative Auditor General
Managed Care Background
2 Managed Care Plans
– Molina (23.3%)
– Healthy U (15.2%)
1 State Run Plan
– Select Access (29.5%)
FOR MORE INFORMATION
See Chapter I, pgs 4 & 5 and Chapter II, pg 11
Slide 22Office of the Legislative Auditor General
Few Cost Control Incentives
Have Existed
Cost-Plus Contracts Rewarded Higher Utilization Leading To Higher Overall Costs
Utah Medicaid Inadequate Oversight
Result: Excess Costs in Managed Care
FOR MORE INFORMATION
See Chapter II, pages 13-18
PMPMs of Managed Care Plans
Office of the Legislative Auditor General Slide 23
Rate Cell Molina Select Access Healthy U
Male Children $108 $109 $102
Male Adults $420 $328 $334
Female Children $109 $106 $100
Female Adults $361 $322 $322
Disabled Males $816 $685 $723
Disabled Female $823 $723 $751
Male Babies $206 $202 $190
Female Babies $193 $241 $171
Pregnancy $522 $497 $535
Slide 24Office of the Legislative Auditor General
Cost Savings Estimate
$16—20 Million Optimal
$6—12 Million Realizable
FOR MORE INFORMATION
See Chapter III, pages 26-32
Slide 25Office of the Legislative Auditor General
Past ER Payment Error
Will Produce Savings
Utah Medicaid Overpaid Hospitals $14 Million for non-reimbursable ER Costs
The costs are collectable
FOR MORE INFORMATION
See Chapter VI, 66 to 71
Slide 26Office of the Legislative Auditor General
Quality of Care Oversight Good,
But Can Improve
Current Oversight Compliance Driven
To Improve
– Set Better Performance Goals
– Better Document Corrective Action
– Standardize Reports
FOR MORE INFORMATION
See Chapter V, pages 55 to 64
Utah Medicaid Provider Cost Control
Utah Legislative Auditor General
January 2011
Slide 28Office of the Legislative Auditor General
Background of Audit
Department of Health Executive Director’s response to the 2009 audit - fraud, waste, and abuse does not occur in Utah like it does in other states.
Speaker of the House/Chair of the Audit Sub-committee in response - we will send out our auditors to see if there is fraud, waste, and abuse in your program.
Slide 29Office of the Legislative Auditor General
Medicaid Fraud, Waste, and Abuse Is a
Concern in Utah
First – Upcoding (overcharging) Is a Problem in Utah Medicaid
Second – Utah’s Fraud, Waste, and Abuse Rate Is Comparable to Other States
Third – Current Cases Show Examples of Fraud, Waste, and Abuse
FOR MORE INFORMATION
See Chapter II, pages 9 to 23
Slide 30
Clinics Frequently Billing 99215 Code
Office of the Legislative Auditor General Slide 30
Clinic Number of Times Code Billed
DOH Salt Lake Clinic 718
A Private Health Clinic 539
Provider 3 333
Provider 4 329
Provider 5 274
FOR MORE INFORMATION
See Chapter II, page 13
Slide 31Office of the Legislative Auditor General
Department of Health Owned Clinic
Independent Review Found:
– 99 percent of claims upcoded or
overcharged
– 73 percent upcoded two or more levels
– DOH management members also upcoded
FOR MORE INFORMATION
See Chapter II, pages 11 to 17
Slide 32Office of the Legislative Auditor General
Private Clinic
Program Integrity Review Found:
– 88 percent of claims upcoded or
overcharged
– 56 percent upcoded two or more levels
FOR MORE INFORMATION
See Chapter II, page 17
Slide 33Office of the Legislative Auditor General
Medicaid Paying for the
Transportation of Unborn Babies
Problem Has Existed For At Least 5 Years
Problem Has Been Identified 3 Times
FOR MORE INFORMATION
See Chapter III, pages 26 to 27
Slide 34
Utah Medicaid Paying More Than PEHP
Office of the Legislative Auditor General Slide 34
Drug Percent Utah Medicaid
Higher Than PEHP
Drug A 64%
Drug B 51%
Drug C 47%
Drug D 40%
Drug E 39%
Drug F 39%
Drug G 35%
Drug H 26%
Drug I 26%
Slide 35Office of the Legislative Auditor General
Audit Results
$20 million budget cut to force efficiencies
BPI collections up from $3 to $15 million per year
Renegotiated managed Care contract savings of $7 million per year
OIG established