State Program Update Panel
PHA Annual Conference
Laurie Rock
Pamela Mailey
May 17, 2012
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Discussion Points
• Explain the Bureau of Program Integrity responsibilities
• Discuss Medical Assistance regulatory requirements
• Discuss relevant elements of Affordable Care Act
• Providers’ responsibility to screen employees
• Common review findings
• Questions
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Bureau of Program Integrity
Federally mandated function to:
• Prevent, identify and combat fraud, waste and abuse within
the Medical Assistance program
• Monitor providers’ compliance with Medical Assistance
regulations and requirements
• Ensure Medical Assistance recipients receive quality care and
do not abuse their benefits
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Bureau of Program Integrity
Responsibilities include:
• Evaluate services and claims for compliance
• Monitor recipient overuse or abuse of services
Presentation Title
• Refer to civil and criminal agencies
• Enforce administrative actions
• Conduct outreach andPresenter
education
Date
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Bureau of Program Integrity
Fraud
• an intentional deception or misrepresentation made by a person with the
knowledge that the deception could result in some unauthorized benefit to
that person or some other person
Abuse
• provider practices that are inconsistent with sound fiscal, business, or
medical practices, and result in an unnecessary cost to the Medicaid
program, or in reimbursement for services that are not medically
necessary or that fail to meet professionally recognized standards for
health care
Waste
• not currently defined in federal Medicaid regulations
• generally understood to encompass the over-utilization or inappropriate
utilization of services and misuse of resources, and typically is not a
criminal or intentional act
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Regulations and Other Instructions
Federal
• Program integrity – 42 CFR Part 455
• Utilization control – 42 CFR Part 456
State
•
•
•
•
– 55 PA Code
Chapter 1101 – General Provisions
Chapter 1150 – Payment Policies
Chapter 1130 – Hospice
Chapter 1249 – Home Health
MA Provider Bulletins
• 37-02-01 – findings from hospice reviews
Provider Handbooks/Billing Instructions
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Regulations
General Provisions – 55 PA Code §1101
•
•
These regulations apply to all enrolled providers
Based on state and federal laws
Some important sections include:
55 Pa Code §1101.51 (e) – records must:
•
Medical and fiscal records must disclose nature and extent of
services
•
Contain documentation of medical necessity of ordered,
rendered and prescribed services
•
Be available for review/copying
•
Be retained for a minimum of 4 years
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Regulations
Some important sections include:
55 Pa Code §1101.75 (a) and (b) – Provider prohibited acts:
•Violations of these are the most serious
•Some violations are considered criminal acts subject to
investigation and prosecution by Medicaid Fraud Control Unit
•Subject to enforcement actions by DPW and restitution
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Regulations
Some important sections include:
55 Pa Code §1101.66 – Compensable services – must be:
•Medically necessary
•Not in excess of need
•Not solely for recipient convenience
•No payment for services or items by providers terminated from the
Medical Assistance program
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
Provider Enrollment Screening
Level of screening will depend on risk of fraud, waste, & abuse
•
Limited risk
 Verify compliance with applicable federal and/or state requirements
 License verification
 Database checks – e.g. EPLS, LEIE, SSI master death file
 Moderate risk (includes hospice organizations)
 All limited risk requirements and
 On-site visits – pre- and post enrollment
 High risk (includes newly enrolling home health and DME suppliers)
 All limited and moderate risk requirements and
 Conduct criminal background checks and fingerprinting (states not
required to implement until additional guidance is issued)
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
• Adjustment of risk levels
• Level of risk must move to high if a payment suspension is
imposed (based on credible allegation of fraud)
• Level of risk must move to high if provider has been excluded in
the past 10 years
• Level of risk must move to high for 6 months following any
temporary enrollment moratoria
• MA may rely on results of screening from:
• Medicare contractors
• MA or CHIP agencies from other states
• Revalidation – States must revalidate all enrolled providers every
5 years
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
• Compliance Programs
• HHS is required to establish compliance program
requirements and timeline for establishment of core elements.
• Compliance program is a condition of enrollment for Medicare,
Medicaid, and CHIP providers and suppliers.
• Enrollment and NPI of Ordering or Referring Providers
• All ordering and referring physicians and other professionals
under the State plan or waiver program must be enrolled in
Medicaid as a participating provider.
• NPIs must be on all claims for payment of ordering and
referring physicians and other professionals.
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
Reporting and Returning Overpayment
• Providers, suppliers, Medicaid MCOs, Medicare Advantage
plans, and PDP sponsors must report and return
overpayments to HHS, the State, or a Medicare intermediary
or carrier by the later of:
• 60 days of identification of overpayment, or
• the due date of the cost report.
• Treble damages and CMPs up to $50K for knowing failure to
return overpayments on time.
• Knowing and failure to report may also be considered a false
claim under the Federal False Claims Act.
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
Payment Suspension/Credible Allegation of Fraud
• HHS may suspend and the State must suspend payments to
individuals or entities based upon credible allegations of fraud,
unless HHS/the State determines there is good cause not to
suspend payments.
• Applies to Medicare and Medicaid.
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Affordable Care Act
Face to Face Encounters
•
Proposed rules for Medicaid issued July 12, 2011 (42 CFR part 440)
• Must occur and be documented 90 days prior or 30 days after order
for home health or DME (for Medicaid)
• Can be done by a physician or non-physician practitioner
• Nurse
• Nurse practitioner
• Clinical nurse specialist
• Certified nurse midwife (not allowable for DME)
• Physician assistant
•
However, documentation of the face-to-face encounter is the physician’s
responsibility
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Recovery Audit Contractor Program
 The State must establish a RAC Program consistent with State law
by 1/1/12.
 RAC must identify overpayments and underpayments.
 The State must pay RACs on a contingency fee basis for recoveries
of overpayments.
 State appeals procedures must apply.
 RACs must coordinate with other reviewing entities and law
enforcement.
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Medical Assistance Bulletin 99-11-05
Provider Screening of Employees and Contractors for
Exclusion and Effect of Exclusion
• 42 CFR 1001.1901 (b) - ”no payment will be made by Medicare,
Medicaid, or any other Federal Health Care program for any item
or service furnished, by an excluded individual or entity, or at the
medical direction or on the prescription of a physician or other
authorized individual….”
• Providers should screen monthly
• Sources to use for screening checks:
• PA Medicheck List
• List of Excluded Individuals/Entities (LEIE) – federal listing
• Excluded Parties List System (EPLS)
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Hospice Reviews
Include review of:
•Hospice care
•Pharmacy
•DME
•Inpatient services
•Home health services
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Common Violations
•Lack of Medical Necessity
•Inappropriate Level of Care/Services
•Inappropriate Revocations
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Record Keeping Violations
• Missing/Incomplete MA 372 Certification of Terminal
Illness Form
• Election of Hospice Form MA 373 not completed
• Incomplete Records
Current Findings/violations are consistent with past review
periods.
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011
Questions
Contact Information:
Laurie Rock
Director
Bureau of Program Integrity
717-772-4606
Lrock@pa.gov
Pamela Mailey
Director
Division of Program and Provider Compliance
717-772-4606
Pmailey@pa.gov
OFFICE OF ADMINISTRATION
MEDICAL ASSISTANCE PROGRAMS | September 30, 2011