Division of Audit and Program Integrity
Division Chief: Eugene ( Gene) Grasser
Program Integrity provisions of Patient Protection and Affordable Care Act
Recovery Audit Contractor (RAC)
Coordinate administrative remedies under Tennessee False Claims Act with TN Attorney
General
Office of Audit/Investigation: Vicki Guye
Conduct Internal/external audit
Perform Desk/field investigations
Deficit Reduction ACT (DRA) compliance
Coordinate Payment Error Rate measurement (PERM)
Electronic Health record (HER) verification and audit
Office of Program Integrity: Dong Siegel
Surveillance and Utilization Review (SURS), claim/encounter based data mining
Track fraud referrals (recipient and provider)
Maintain Provider Fraud Task Force (PFTF) database
Managed Care Contractor program integrity compliance
Liaison with CMS Medicaid Integrity Group (MIG) & Medicaid Integrity Contractors (MIC)
RAC coordination
CMS: Center for Program Integrity
Medicaid Program Integrity Provisions
Presentation based on new Medicaid Program Integrity provisions of HR
3590 – Patient Protection and Affordable Care Act
Some final regulations have been issued by CMS ( Provider Enrollment
and Screening – 2/2/11) and others are still in the NPRM status (RAC 11/10/2010)
CMS has also issued clarifying State Medicaid Letters
Letters to State Medicaid Agencies –
Preliminary Guidance on CMS Website
Medicaid Program Integrity Provisions – Section 6401
Provider Screenings and Enrollment Requirements - Medicare
Medicaid Screening Process Must Parallel Medicare
Medicare and Medicaid Screening provisions are not applicable to providers
enrolled in Part C Medicare managed care plans or Part D Medicare drug
plans or Medicaid Managed Care Plans
Medicare requirements for New Providers
Level of Screening - Depends on classification of provider
Limited: individual practitioner, hospital, ASC , FQHC,SNF,..
Moderate: Ambulance, CMHC, CORF, hospice, …
High: newly enrolling HHA & DME
Medicaid Program Integrity Provisions – Section
6401
Provider Screenings and Enrollment Requirements - Medicare
Medicare (Medicaid) requirements for each Level
Limited: exclusion database checks, license verification, disclosure
Moderate: Limited level plus: additional on-site visit
High: Moderate level plus: criminal background checks,
fingerprinting, unscheduled and unannounced site visits
Required Enrollment and Screening Application Fees
2010 - $500 and adjusted for inflation
Providers are only required to pay one fee per enrollment period to Medicare or a
state Medicaid program
Medicaid Program Integrity Provisions – Section
6401
Provider Screenings and Enrollment Requirements - Medicare
New Providers - Medicare
Provisional Period – 1 Year Enhanced Oversight
Prepayment review , Payment caps, etc.
Increased Disclosure – Affiliations on Disclosure - Reasons to Deny
Enrolment
Uncollected Overpayments
Suspension or Revocation of Billing Privileges Medicare or Any State
DHHS Secretary may Issue Temporary Moratoriums on Enrollment if
necessary for F&A issues & States may request a state moratorium
Medicaid Program Integrity Provisions – Section
6401
Provider Screenings and Enrollment Requirements - Medicare
Current Providers – Medicare
Revalidation of Enrollment
Starting 180 days after passage
Procedures apply to providers within two years of enactment
Within 3 years of Enactment - No providers will remain without
revalidation
Medicaid Program Integrity Provisions –
Section 6401
TennCare MCO Provider Enrollment and Screening Requirements
Although Providers in TennCare MCO’s will not be subject to the new enhanced Medicare &
Medicaid Fee For Service provider Enrollment and Screening Requirements, TennCare
MCO’s must continue to perform the following enrollment procedures, as well as, Provider
Credentialing and getting a TennCare ID# for the provider in addition to any additional
requirements mandated by the MCO’s internal rules and procedures
Collect Basic demographic information
Collect W-9 form (taxpayer ID)
Verify NPI number
Require submission of Disclosure of ownership & control information
Verify License
Collect SSN #
Check against:
HHS OIG exclusion list
Tax delinquency
Death file
Request a TennCare Provider number prior to reimbursing the provider
Medicaid Program Integrity Provisions – Section
6401
Increased Disclosure Requirements
Who
Medicaid providers, fiscal agents and managed care entities
What
1. Name and address of individual or corporation with ownership or control interest
2. Date of birth and SSN for individual
3. Other Tax information corporation with ownership & control and subcontractor in which
the disclosing entity has a 5% interest
4. Information must be provided whether the person with ownership is related to another
person with ownership or control in the disclosing entity or whether the person or entity with
the ownership or control interest in a subcontractor has a 5% or more interest is related to
another party with ownership or control in the disclosing entity
5. Name, address, DOB, & SSN of managing employees of disclosing entity
6. Medicaid/Medicare convictions and/or exclusions
When
Providers: 1. Submitting application, 2. Request by Medicaid & 3. Ownership change
Fiscal Agents & MCO’s: 1. RFP proposals, 2. Execute Contract, 3. Renewal & 4. Ownership
Change
*Disclosure is also required by TN statue: T.C.A.71-5-137 & T.C.A.8-50-502
Medicaid Program Integrity Provisions – Section
6402
Data matching - Integrated Data Repository a data repository Medicare (A, B, and C &D),
Medicaid, CHIP, VA, DOD, SSI, IHS, etc.
Beneficiary in Health Care Fraud Scheme - Administrative Remedy for Knowing
Participation by a Beneficiary in Health Care Fraud Scheme will be assessed against
enrollees that participated in health care schemes.
*TN Statute T.C.A.71-5-2601 also makes certain actions of this type a Class E Felony
National Provider Identifier - January 2011 Requires all providers and suppliers that qualify
for a national provider identifier to include this identifier on all applications for enrollment.
Medicaid Statistical Information System (MSIS) - Permits the withholding of federal
matching payments for states that fail to report enrollee encounter data.
Permissive Exclusions - Allows permissive exclusions for individuals or entities that
knowingly make false statements or misrepresentations of material facts.
Medicaid Program Integrity Provisions – Section
6402
Deterrence/Civil and Criminal Penalties - Amends the Anti-Kickback statute so that a claim
that includes items or services violating the statute would also constitute a false or
fraudulent claim. These CMP’s can be up to $50,000 or up to 3 times the amount of the
claim for each item or service for which the payment was made based on the application
containing the false statement or misrepresentation of a material fact.
Subpoena Authority - Grants the Secretary subpoena authority in exclusion-only cases. The
DHHS OIG will be given subpoena authority.
Medicare and Medicaid Integrity Programs - Requires entities that are enrolled in Medicare
and Medicaid to submit performance statistics on the number of fraud referrals,
overpayments recovered, and return on investment. (Sec. 6402 of H.R. 3590)
Section 6402 – Overpayments
A provider, supplier, Medicare Part C or Part D plan and Medicaid managed care plans
must report and return overpayments to Medicaid with 60 days of their identification or be
subject to the Federal False Claims Act. MCO’s were notified in March 2011 and tasked to
notify providers.
Medicaid Program Integrity Provisions – Section
6402
Suspension of Payments for a Credible Allegation of Fraud
455.2 - Definitions - May be verified from any source but not limited to:
1. Fraud hot line
2. Claims Data mining
2. Patterns from provider audits, civil false claims, law enforcement
investigation with an indicia of reliability which has been reviewed by Medicaid
455.23 – 1. Agency must suspend after determining a credible allegation of fraud for
which there is an investigation pending unless good reason not to suspend
2. May suspend without first notifying
3. Provider may request and must be granted administrative review
4. Within 5 days of suspension unless requested not to by law enforcement
5. Within 30 days if law enforcement requests not to notify
6. Suspension is temporary and will not continue if Agency or prosecuting
authority determines insufficient evidence or legal proceedings of alleged
fraud are completed.
Medicaid Program Integrity Provisions
Section 6403 - National Practitioner Data Bank
DHHS will maintain a national fraud and abuse data bank for reporting
adverse actions against providers.
Section 6411 – Recovery Audit Contractor (RAC)
By 12/31/2010 states shall contract with a contingency fee based RAC.
NPRM issued on 11/10 2011
TennCare’s competitive procurement selected HMS as Medicaid RAC
Contract effective 2/1/2011 and is being implemented
Section 6501 - Termination of Provider participation
States shall terminate any individual or provider that has been excluded
from Medicare or another state.
Medicaid Program Integrity Provisions
Section 6502 – Medicaid Exclusion from Participation
Requires State Medicaid agencies to exclude from participation for a
period any entity that has unpaid overpayments, is suspended or
excluded from participation or is affiliated with an entity suspended
or excluded.
Section 6503 - Required Registration under Medicaid
Requires agents, clearinghouses or alternate payees to register.
Section 6505
Prohibits paying for services to institutions located outside the US.
Recovery Audit Contractor
Introduction
In accordance with Section 6411 of the Patient Protection and Affordable Care Act,
TennCare issued an RFP, HMS, was selected with an effective date of February 1,
2011. A required Medicaid State Plan Amendment was submitted.
Reimbursement
The RAC contractor will be funded on a contingency fee basis and only receive
reimbursements from recovered funds in accordance with 42 CFR 455.510. Funds
will only be considered recovered at the conclusion of any and all appeals available to
the provider pursuant to TennCare Rule 1200-13-18.
Coordination of PI efforts between TennCare, the MCOs and the RAC
All Potential RAC recoveries must be presented to TennCare OPI for review.
The RAC will not be allowed to pursue a recovery for a provider & issue previously
identified by an MCC, TennCare or law enforcement.