Medicaid Educational ConferenceDecember 7, 2016
Elizabeth Smith
Medicaid Inspector General
Mission of OMIG:
To detect and prevent fraud, waste, and abuse within the medical assistance program.
OMIG’s Requirements
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 to the Medicaid program.
Prevent waste in the program
Identify policies needing revision• Unclear
• Too broad
• No longer necessary
• Too restrictive
• Negative impact on outcome
Implement changes to Medicaid programs
ABC’s of Medicaid Auditors• OMIG - Office of Medicaid Inspector General• MIC - Medicaid Integrity Contractor (Health
Integrity)• ZPIC/UPIC – CMS Program Integrity Contractors • SURS - Medicaid Utilization and Review audits• QIO - Quality Improvement Organizations• Ark. Legislative Audit – auditing Ark. Medicaid
Program by review of provider billing
OMIG Data AnalyticsFraud Detection System – billing claims
• Provider Spike Detection
• Peer Review Analysis and Outlier Identification
• Algorithms
• Claims Risk Analysis
Top outliers are selected for audit– When billing stands out from the average in a peer
group
Or send Provider Awareness Letter – request provider review billing practices in lieu of audit
Data Analysis Report– Individual provider’s values for reviewed behavior patterns– Peer group averages for reviewed behavior patterns– Claims detail for all claims included in behavior pattern
calculation
if billing is determined to be improper – corrective action plan
AUDIT PROCESSESField 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
AUDIT PROCESSES
Desk 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• Enrollment Contract requirement • §151.000 - Grounds for Sanctioning Providers
Subpoena Power and Production of Records• Ark. Code Ann. §20-77-2506
• Records may be requested from providers when they are not being audited
• Subpoena employment records
• Subpoena records to determine overlapping services
• Records request for Medicaid providers utilizing hospital facilities
AUDIT RESULTSWill be provided in Audit Report Letter• Findings
• Recovery or Recoupment/Corrective Action Plans*• Area of Concern• Observations • No findings• MFCU/Law Enforcement Referral
• Credible allegation of fraud-requires temporary suspension; possible suspension of performer only
Corrective Action Plans
• Based on OMIG Audit Report
• Develop plan of action addressing findings,observations, and areas of concern
• Be specific in your steps and procedure
• Provide a person/name/position for accountability
• OMIG.ARKANSAS.GOV
Corrective Action Plans
Website
steps
Self-Reporting & Self-Disclosure• Protocols for efficient self-disclosure
• Provider’s good faith -a mitigating factor
• Self-Disclosure Protocol on OMIG website
• OMIG.Arkansas.gov
• Reversing claims-Creates uncertaintyregarding questioned claims
OMIG FY 2016 REPORTField Audits 78 Desk Audits 237Recoupment Letters 1033 MIC Reviews 2Provider Awareness Letters 42 False Claims Act Rev. 124
total: 1516Provider Self-Reports 18
Recoupments & Recoveries $2.7 Million
Provider Fraud Referrals 51 (33 NPIs) 11 arrests and 13 suspensions of enrolled performing providers
Beneficiary Fraud Referrals 38
Crossover ClaimsSchool District Matching FundsEmergency TransportationPhysician & Advanced Practice Nurse BillingHospital One-Day Stay Reviews90853 Group PsychotherapyProvider Awareness LettersHHS/OIG Herceptin Claims
Continued Crossover ClaimsSchool Based Therapy reviewsPersonal Care Assistants and Home Health Service Worker Registration ProjectPeer Group Studies and Batch ReviewsRecommendations for Reform and Provider Manual Changes
Elizabeth Smith
Medicaid Inspector General323 Center Street, Ste. 1200
Little Rock, AR 72201
501-682-8349
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