Improving Medicaid Program Integrity: State Strategies to Combat Fraud and Abuse

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1 Improving Medicaid Program Integrity: State Strategies to Combat Fraud and Abuse March 6, 2013 Overview New York's Experience Role of Medicaid Program Integrity: Florida s Approach Medicaid Anti-Fraud and Abuse Practices: Database from The Pew Charitable Trusts 1

2 Presenters Senator Kemp Hannon, Chair, New York Senate Standing Committee on Health Ken Yon, Interim Bureau Chief, Office of the Inspector General, Florida Medicaid Program Integrity Matt McKillop, Senior Associate, State Health Care Spending Project, The Pew Charitable Trusts Senator Kemp Hannon --- Chair, New York Senate Standing Committee on Health 2

3 Florida Medicaid Program Integrity A Brief Overview A Webinar Presentation to the National Conference of State Legislatures March 6, Directive for Combating Medicaid Fraud, Abuse and Waste Protect the Medicaid idrecipient i Protect the program Protect limited $ 6 3

4 Combating Medicaid Fraud, Abuse and Waste It s Everyone s Business Better Health Care for All Floridians 7 The Formula for Success Includes Outside Partnerships Law Enforcement (MFCU, FDLE) AHCA (Medicaid, MPI, HQA) Executive/ Legislative Centers for Medicare & Medicaid Services Regulatory Agencies (DOH, APD, DFS) 8 4

5 MPI Detection Leads Complaints Other regulatory announcements or actions Intra Agency Bi-monthly Meetings (AHCA, MFCU, DOH, etc.) NAMPI, TAG, Quad State Conference Calls (CA, FL, NY, TX) Incoming referrals Newspaper articles and ads Detection program reports (1.5 Report, Chi Square Rpt, Early Warning Report, etc.) Investigator Situational Analysis (Billings, Policy, Coverage) Investigator What If Adhocs Data analysis (e.g., DSS Profiler) Leads from Medicaid Medi-Medi Partnership Explanation of Medicaid dbenefits e s( (EOMB) Payment Error Rate Measurement (PERM) Recipient movement (Follow the $) Issues Enhanced by Prescribers Not Enrolled in Medicaid Hotline 9 MPI Intervention Menu Prevention Detection On-Site Visits Collaborative Field Initiatives Prepayment Reviews Termination Recommendations Recommend Limitation of Prescribing Rights Referrals to MFCU, DOH, HQA, FDLE, etc. Creditable Allegations of Fraud Withholds Self Audits Recommendations Prior Authorization Suggestions Recommend Recipient Lock Ins Sanctions (Fines, Susp., Term.) Education Policy & Edit Recommendations Legislation Recommendations Recoupment ID Overpayment Audits and Final Orders (Comprehensive & GAs) Self-Audit Processing Paid Claim Reversals Credit Adjustments (by Medicaid) Third Party Liability 10 5

6 Other Points of Interest Applicants undergo background checks and previous program history checks Terminations may be based on Provider or Associated Persons Events Terminations may be contractual or for cause Florida takes like action for suspension or termination performed by Medicaid, Medicare, other states Terminations enacted for failure to pay overpayments Providers are subject to sanctions, e.g., fines Florida recovers costs to perform audits Florida recoups overpayments during the litigation process Florida posts Final Order actions on website Telephonic Home Health Services Delivery Monitoring and Verification Program

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10 19 Combating Medicaid Fraud and Abuse State Health Care Spending Project March 6,

11 State Health Care Spending Project Wrong recipient. $11 Billion State Medicaid Improper Payments Source: CMS Right recipient receives incorrect amount of funds. Cost Containment Insufficient documentation. Recipient uses funds improperly. State Health Care Care Spending Project Project 11

12 State Health Care Care Spending Project Project State Health Care Care Spending Project Project 12

13 Provider Accountability Excluding Problem Providers Provider Regulation Prepayment Review Service Verification Prior Authorization and Claims Review Recipient Lock In Data Mining Detection and Investigation Penalties and Recovery Medicaid Fraud Control Unit Coordination Post Payment Recovery Stakeholder Coordination Provider Outreach and Education Managed Care Oversight Cross Cutting Targeting High Risk Providers State Health Care Care Spending Project Project Provider Accountability Excluding Problem Providers Provider Regulation Florida Automated license verification process. State Health Care Care Spending Project Project 13

14 Service Verification Prior Authorization and Claims Review Recipient Lock In Pre Payment Review New York Patients swipe benefit cards. Select providers must post orders before another provider can bill the transaction. Combined cost savings of $683 million from 2008 to State Health Care Care Spending Project Project Data Mining Detection and Investigation Penalties and Recovery Medicaid Fraud Control Unit Coordination Post Payment Recovery Illinois Predictive modeling system to detect aberrant provider behavior early. State Health Care Care Spending Project Project 14

15 California Uses a Medicaid Payment Error Study to identify provider types at greatest risk for payment errors. Stakeholder Coordination Provider Outreach and Education Managed Care Oversight Cross Cutting Targeting High Risk Providers State Health Care Spending Project Majority of states actions are focused on providers. Important to strike balance between combating bti fraud and abuse without overburdening honest providers and harming access. State Health Care Care Spending Project Project 15

16 Affordable Care Act Medicaid Program Integrity Provisions (Among Others) Targeted screening. Temporary enrollment freeze. Payment suspensions. Recovery Audit Contractor (RAC). Coordinated provider termination. State Health Care Care Spending Project Project Return on Investment Total FFY2009PI Expenditures: $394million Total FFY 2009 Recoveries: $2.3 billion Source: CMS State Program Integrity Assessment FY 2009 Executive Summary State Health Care Care Spending Project Project 16

17 Matt McKillop Questions? The webinar archive and power points will be available online next week. Staff Contact: Megan Comlossy 17

18 Upcoming Webinars Community Health Centers Role in the Health System, Now and In the Future Friday, March 8, p.m. ET/ 1 p.m. CT/ Noon MT/ 11 a.m. PT States Help Veterans Access Health Benefits and Save Money, Too Monday, March 11, p.m. ET/ 1 p.m. CT/ Noon MT/ 11 a.m. PT 18