New York State Office of the Medicaid Inspector General Carol Booth, R.N./Auditor, Managed Care Cathy McCulskey, B.S./Data Systems Analysis

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1 New York State Office of the Medicaid Inspector General Carol Booth, R.N./Auditor, Managed Care Cathy McCulskey, B.S./Data Systems Analysis

2 Official Disclaimer The opinions expressed during this presentation are those of Cathy McCulskey and Carol Booth only and do not necessarily represent those of the New York State Office of the Medicaid Inspector General. Thank you.

3 Office of the Medicaid Inspector General New York State s OMIG In 2006, Executive Order No created this independent entity within the Department of Health Our Mission Statement: To improve the efficiency and accountability of the New York State Medicaid program by preventing and detecting fraudulent, wasteful and abusive practices within the Medicaid program.

4 Why we have job security: People Don t t Do What You Expect: They Do What You Inspect

5 Why we can inspect: New York Codes, Rules, & Regulations NYCRR Title 10 Covers managed care programs & fee-for for-service NYCRR Title 18 Covers managed care programs & fee-for for-service Medicaid Managed Care Program Medicaid Managed Care Program - Medicaid Managed Care & Family Health Plus Model Contract - Medicaid Advantage Model Contract

6 Compliance: what does it mean to you? Honesty Integrity Quality Adherence Consistency

7 We ensure compliance by: Monitoring data submissions Identifying unusual patterns Enforcing regulations Recovering inappropriate payments Tracking continued compliance efforts

8 The Inspection Process 1. Identify claims with unusual billing patterns 2. Check claims by dates of service and payment, identify details 3. Match data for accuracy against stringent algorithms 4. Cleanse data via manual review 5. Send findings to healthcare provider

9 The Inspection Process 6. Provide adequate time for provider response 7. Adjudicate provider responses after evaluation 8. Collect repayment void process 9. Monitor submissions through internal tracking reports 10. Identify and target new patterns; repeat steps 1-9!

10 New York State cares about its mothers and babies

11 But we do take issue with claims for: Men having babies

12 Deceased enrollees

13 Or inpatient transportation.

14 We ve seen other billing miracles, too: Babies being born twice Children under 10 years old having babies Women giving birth every 5 months

15 But wait, there s more! Women having colonoscopies the same day they deliver Women over 50 years old having babies without infertility treatments Women giving birth to themselves!

16 That s where we come in.

17 The Data Warehouse A powerful database containing all of the information on enrollees, managed care plans, facilities, providers and payments within the Medicaid program.

18 Inside the Data Warehouse Hundreds of modules Thousands of tables Millions of data elements Billions of claims Mapping capabilities Analytical capabilities

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20 The Recipient module is one of the smallest in the Warehouse

21 Each table is populated with multiple data elements This table, one of 20 that lie within the Recipient module, contains data elements relating to the beneficiary.

22 Reports from the Data Warehouse Our success in data mining and the resulting recovery reports we generate are overwhelmingly driven by the healthcare industry s s own unhealthy billing practices! Much of the supporting documentation we send providers as attachments to our recovery letters are derived from the Data Warehouse system

23 Providers can avoid improper billings and further state action Before submitting claim data, test it for accuracy Utilize robust software to evaluate claim data for anomalies on an ongoing basis: - cross-matched data - weighted algorithms

24 Other improper claims Excessive services/units - unbundling Medicare rates billed daily - dialysis, mental health, & methadone maintenance Children with no immunizations or well care visits - under-utilization of services Providers billing for patients with conflicting services - 20 minute & 40 minute evaluations: same day, same provider Items normally included in rates are billed separately - SNF/ALP & bandages, alcohol, aspirin

25 Providers: The Good, The Bad, & The Ugly The Good: Compliant The Bad: Semi-Compliant The Ugly: Non-Compliant

26 State action: what we will do The Compliant: we will help by sharing the methodology and criteria used The Semi-Compliant: we will inspect on site, often discovering more errors and the Non-Compliant? Well

27 Just kidding.

28 What we have done. Recovered improper payments Charged interest Imposed penalties and sanctions Prosecuted

29 Taking Corrective Action Use the void process rather than repaying by check: Why? Corrects data permanently - avoid future re-inspection by other agencies May be used for compliance planning process - proof of corrective action taken

30 In Summary Providers need to do what is expected. The State will take action. The Ugly will be prosecuted.

31 References Carol Booth Catherine McCulskey