Partnering in HealthChoices Behavioral Health Program Compliance and Integrity Fraud, Waste and Abuse (FWA) Detection, Deterrence, and Prevention

Transcription

1 Partnering in HealthChoices Behavioral Health Program Compliance and Integrity Fraud, Waste and Abuse (FWA) Detection, Deterrence, and Prevention Module 1/3 "FWA 101 September Community Care Behavioral Health Organization

2 Overview The purpose of this training is to further develop the Community Care and Provider Network partnership to detect, deter, and prevent fraud, waste and abuse (FWA) in the Behavioral Health HealthChoices program This is the first of a 3-part educational series of modules designed to increase awareness of FWA principles, requirements, audit processes, and resources Modules: Fraud, Waste and Abuse - Detection, Deterrence, and Prevention: FWA 101 Fraud, Waste and Abuse - Detection, Deterrence, and Prevention: Community Care FWA Audit Processes Fraud, Waste and Abuse - Detection, Deterrence, and Prevention: Building Program Integrity Compliance 2017 Community Care Behavioral Health Organization 2

3 Training Objectives: Module 1 This first module will cover the following topics: 1. Fraud, waste and abuse definitions and examples 2. Support, regulatory guidance, education, and consultation for providers to achieve and sustain Medical Assistance/Medicaid billing compliance 3. Commonwealth of Pennsylvania and federal agencies regulations, statutes, and requirements related to program integrity/fwa: Centers for Medicare & Medicaid Services (CMS) Department of Human Services (DHS) Pennsylvania Bureau of Program Integrity (BPI) Office of the Attorney General (AG) Office of the Inspector General (OIG) Office of Mental Health & Substance Abuse Services (OMHSAS) 4. HealthChoices Behavioral Health Program Standards & Requirements (PSR) Appendix F: Fraud and Abuse (Appendix F) 5. Compliance plan elements 6. Precluded provider screening 2017 Community Care Behavioral Health Organization 3

4 Glossary of Acronyms ACA AG BHMO BPI CHIP CFR CMS CPI DHS DMF DRA DOJ EPLS FFCA FFS FWA GAO IG Affordable Care Act Office of the Attorney General Behavioral Health Managed Care Organization Bureau of Program Integrity Children s Health Insurance Program Code of Federal Regulations Centers for Medicare & Medicaid Services Center for Program Integrity Department of Human Services Social Security Death Master File Deficit Reduction Act Department of Justice Excluded Parties List System Federal False Claims Act Fee for Service Fraud, Waste and Abuse Government Accounting Office Inspector General 2017 Community Care Behavioral Health Organization 4

5 Glossary of Acronyms LEIE MA MCE MCO MIG MFCS MMIS NHCAA NPI OIG PPACA PERM PI SIU List of Excluded Individuals and Entities Medical Assistance Managed Care Entity Managed Care Organization Medicaid Integrity Group Medicaid Fraud Control Section Medicaid Management Information System National HealthCare Anti-fraud Association National Provider Identifier Office of Inspector General Patient Protection and Affordable Care Act Payment Error Rate Measurement Program Integrity Special Investigative Unit 2017 Community Care Behavioral Health Organization 5

6 Oversite Entities Commonwealth Federal Primary Contract Administrator Community Care DHS CMS State Policies BPI DOJ County Website OMHSAS MFCS OIG AG Joinder Provider Manual Provider Alerts *Offices may be on the federal and/or state level Fee Schedule 2017 Community Care Behavioral Health Organization 6

7 Partnership to Combat FWA DHS/BPI CMS OMHSAS Fraud Providers Members BH-MCO 2017 Community Care Behavioral Health Organization 7

8 Definition of Fraud Appendix F What is Fraud in Behavioral Health HealthChoices? Fraud: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. It includes any act that constitutes fraud under applicable Federal or State law. Knowingly or intentionally submitting false claims Examples: To purposely bill for services that were never delivered To bill for a service at a higher reimbursement than the service rendered Rounding up of time in service delivery when not permitted 2017 Community Care Behavioral Health Organization 8

9 Definition of Waste Appendix F What is Waste in Behavioral Health HealthChoices? Waste: As defined by CMS, Medicare Part D: The overutilization of services or other practices that result in unnecessary costs. Generally not considered caused by criminally negligent actions but rather misuse of resources. Examples: Provider ordering excessive testing Recipient using excessive services such as office visits 2017 Community Care Behavioral Health Organization 9

10 Definition of Abuse Appendix F What is Abuse in Behavioral Health HealthChoices? 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. It also includes recipient practices that result in unnecessary cost to the Medicaid program. Examples: Services that are billed by mistake Misusing codes ~ code on claim does not comply with national or local coding guidelines; not billed as rendered Billing for a non-covered service Inappropriately allocating costs on a cost report 2017 Community Care Behavioral Health Organization 10

11 MIP Compliance Function: The Centers for Medicare & Medicaid Services (CMS) asserts a commitment to combat Medicaid provider fraud, waste and abuse, which diverts dollars that could otherwise be spent to safeguard the health and welfare of Medicaid recipients. In 2006, the Deficit Reduction Act (DRA) was signed into law and created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act. CMS responsibilities under the MIP include: Hire contractors to review provider activities, audit claims, identify overpayments, and provide education on Medicaid program integrity issues Provide support and assistance to states in their efforts to combat provider fraud and abuse On the state, joinder, and county levels, Community Care works closely with the Primary Contract Administrators, Office of Mental Health and Substance Abuse Services (OMHSAS) and the Department of Human Services (DHS), Bureau of Program Integrity (BPI) to carry out the FWA compliance and program integrity program as required in HealthChoices Community Care Behavioral Health Organization 11

12 MIP Compliance The Behavioral Health HealthChoices Program Standards and Requirements (PSR) Appendix F: Fraud and Abuse describes the requirement for each Behavioral Health Managed Care Organization (BHMCO) to operate a Special Investigations Unit (SIU) to conduct FWA activities including: Detection Deterrence Prevention The PSR can be found on the DHS Website at Each BH-MCO and provider is required to have a formal Compliance Plan (process and document) in place to serve as a roadmap to address organizational integrity including the detection, deterrence and prevention of FWA Community Care Behavioral Health Organization 12

13 Compliance Plan Definition: A document developed by the organization s compliance program detailing fraud, waste and abuse prevention strategies and reporting methods. A well-structured compliance program includes a written document, termed a compliance plan, that details the means by which an organization will conform to specific regulations to achieve and maintain compliance. The compliance plan defines standards, describes the methods for monitoring standards, and identifies corrective action processes. Purpose: A Compliance Plan is a guide to ensure adherence to regulations regarding coding, billing, and service delivery, which includes a plan and strategy to prevent and manage fraud, waste and abuse. Community Care Contractual Compliance Plan Requirements Related to FWA: Contracted individuals, facilities or community-based providers must have a Compliance Plan in place which includes regularly scheduled FWA training Providers are required to measure the sufficiency and adherence to their Compliance Plan Upon request, provider attests annually to the completion of FWA training for agency staff for the preceding calendar year and the proposed training schedule for the upcoming year Primary Contract will receive a copy of a provider s Compliance Plan (upon request) as well as an annual summary of provider FWA training completion and schedule of ongoing FWA training 2017 Community Care Behavioral Health Organization 13

14 Comp. Plan: Contractual Requirement Provider submits a copy of their Compliance Plan to Community Care at the following intervals: Prior to credentialing Re-credentialing Upon revision or amendment During audit (FWA, Quality, etc.) During any site visit Upon request Community Care will validate inclusion of the FWA training requirement at the above intervals Network Provider Relations will store these plans and provide them to the Primary Contract Administrator upon request Reference: Provider Alert #9: Fraud, Waste & Abuse (FWA) Compliance & Program Integrity Update 2017 Community Care Behavioral Health Organization 14

15 Compliance Plan Elements Establish written compliance standards, policies and procedures Specific high-level individual(s) hold responsibility for compliance No delegation of substantial discretionary authority to act on the plan Effective internal and external communications (Example: Community Care Compliance Helpline ) Establishes monitoring and auditing systems designed to detect criminal activity Consistent enforcement through disciplinary mechanisms Response and corrective action must take all reasonable steps to respond to the offense Compliance Plan overall effectiveness 2017 Community Care Behavioral Health Organization 15

16 Compliance: Agency Tools Policies and Procedures Agency Level Precluded Provider Screening Community Care Policies and Procedures Code of Conduct Compliance Committee Designated Compliance Officer or Function Internal Audits External Audits Monthly Reports Corrective Action Plans Compliance is not an event but rather a continuous cycle requiring clinical, operations, and fiscal collaboration for success 2017 Community Care Behavioral Health Organization 16

17 Compliance: Agency Tools Community Care encourages its employees, agents, and others to report instances of wrongdoing Steps for reporting: Employees are encouraged to make an initial written report to their designated supervisor/manager or to their Compliance Officer An individual also may report such concerns by calling the Community Care Compliance Helpline ETHIC ( ) Reports to the Helpline may be made anonymously Community Care prohibits retaliation against anyone for raising, in good faith, a concern or question about inappropriate or illegal behavior 2017 Community Care Behavioral Health Organization 17

18 Building a Compliance Program Affordable Care Act Provider Compliance Programs Getting Started Webinar June 17, 2014 / June 26, 2014 (PowerPoint Slides and narrative) Office of Inspector General U.S. Department of Health & Human Services Compliance Education Materials Compliance Community Care Behavioral Health Organization 18

19 Preclusion, Debarment, Exclusion What does it mean to be excluded from participation in federal health care programs? No federal health care program payment may be made for any items or services furnished, directed or prescribed by an individual or entity who has been determined to be excluded (debarred, precluded) from participation in the Medicaid program. In other words, no claims for payment may be submitted for services rendered by any person, in any capacity, who has been excluded from participation. Payment prohibition extends to: Payment for administrative and management services regardless of whether theses individuals provide direct care to members. Example: salaries and fringe benefits for excluded individuals may not be included on cost reports submitted to DHS Community Care Behavioral Health Organization 19

20 Preclusion, Debarment, Exclusion Who should be screened? All employees, vendors, contractors, service providers, and referral sources Independent providers Facilities Contractors/vendors How often must screening occur? On hire Monthly 2017 Community Care Behavioral Health Organization 20

21 Screening Process & Resources Proactive steps to take now to minimize exposures with your labor force and contractors MA Bulletin : Outlines the requirements for Medicaid providers to do pre-hire and monthly screenings of employees to detect any excluded individuals and entities. Know the bulletin and incorporate the elements into your Compliance Plan. Web-based Screening Portals: List of Excluded Individuals and Entities (LEIE) System for Award Management (SAM) Excluded Parties List System (EPLS) part of SAM DHS Medicheck List 2017 Community Care Behavioral Health Organization 21

22 LEIE Identifies individuals or entities excluded nationwide from participation in any federal health care program If included on the LEIE - Ineligible to participate, either directly or indirectly, in the MA Program sp Community Care Behavioral Health Organization 22

23 SAM Parties are excluded from receiving federal contracts, certain subcontracts and certain federal financial and non-financial assistance and benefits. Providers may not contract with vendors named on the Excluded Parties List System (EPLS) General Services Administration worldwide database Maintains the EPLS Community Care Behavioral Health Organization 23

24 DHS Medicheck List Database maintained by the PA DHS Providers, individuals, and other entities that are precluded from participation in Pennsylvania s MA Program ksearch/ 2017 Community Care Behavioral Health Organization 24

25 U.S. Office Department of Treasury The Office of Foreign Assets Control (OFAC) administers and enforces economic sanctions programs primarily against countries and groups of individuals, such as terrorists and narcotics traffickers. The sanctions can be either comprehensive or selective, using the blocking of assets and trade restrictions to accomplish foreign policy and national security goals Community Care Behavioral Health Organization 25

26 SDN List OFAC publishes a list of individuals and companies owned or controlled by, or acting for or on behalf of, targeted countries. It also lists individuals, groups, and entities, such as terrorists and narcotics traffickers designated under programs that are not country-specific. Collectively, such individuals and companies are called "Specially Designated Nationals" or "SDNs." Their assets are blocked and U.S. persons are generally prohibited from dealing with them Community Care Behavioral Health Organization 26

27 Excluded Individual or Entity If you discover an excluded individual Immediately self-report your findings to the Bureau of Program Integrity (BPI) online through the MA provider compliance form at: neresponseform/index.htm Contact your agency s Human Resources Department Refer to your Compliance Officer and Compliance Plan Complete a Corrective Action Plan (CAP) Self-report to Community Care and the BPI Note: Any services provided, during a period of preclusion, by an individual or entity who has been excluded will require repayment to Community Care. Fines may also be assessed by DHS based on the circumstances. Risks of failure to report: Civil monetary penalty up to $10,000 per CLAIM!!! You are excluded from participation in federal Medical Assistance programs. Protect yourself: Keep a record of the dates you perform screening. Community Care will periodically request to review your screening documentation Community Care Behavioral Health Organization 27

28 Federal False Claims Act (FCA) Federal statute - covers fraud involving ANY federally funded contract or program, including MA. Any individual or organization that knowingly submits a claim he or she knows (or should know) is false and knowingly makes or uses, or causes to be made or used, a false record or statement to have a false claim paid or approved under any federally funded health care program is subject to civil penalties. It also includes those cases in which any individual or organization obtains money to which they may not be entitled, and then uses false records or statements to retain the money, and instances where a provider retains overpayments. Liability may include triple damages and penalties between $10,781 and $21,563 for each false claim. May also result in civil penalties and exclusion from participation in any federal health care program 2017 Community Care Behavioral Health Organization 28

29 FCA: Examples of Violations A provider who submits a bill to Medicare or Medicaid for services that were not rendered A government contractor who submits records that he knows (or should know) are false, which indicate compliance with certain contractual or regulatory requirements A provider that obtains interim payments from Medicare throughout the year, and then knowingly files a false cost report at the end of the year in order to avoid making a refund to the Medicare program Submitting false information about services performed or charges for services performed Inserting a diagnosis code not obtained from a physician or other authorized individual Misrepresenting the services performed (for example, up-coding to increase reimbursement) Submitting claims for services ordered by a provider that has been excluded from participating in Medicare, Medicaid, and other federally funded health care programs Violation of another law. For example, a claim was submitted appropriately but the service was the result of an illegal relationship between a physician and the hospital (e.g., a physician received kickbacks for referrals) 2017 Community Care Behavioral Health Organization 29

30 Anti-Kickback Statute The Anti-Kickback Statute (42 U.S.C. 1320a-7b) is a federal law that prohibits persons from directly or indirectly offering, providing, or receiving kickbacks or bribes in exchange for goods or services covered by Medicare, Medicaid, and other federally funded health care programs. These laws prohibit someone from knowingly or willfully offering, paying, seeking, or receiving anything of value ("remuneration") in return for referring an individual to a provider to receive services, or for recommending purchase of supplies or services that are reimbursable under a government health care program Violations of the law are punishable by criminal sanctions including imprisonment and civil monetary penalties. The individual or entity may also be excluded from participation in Medicare or other federal health care programs for violating the Anti-Kickback Statute. The Office of the Inspector General (OIG) will deem an arrangement as not in violation of the Anti-Kickback Statute when it fully complies with the terms of a safe harbor. Arrangements that are not covered by safe harbor thus do not qualify for automatic protection and may or may not violate the Anti-Kickback Statute. Some states have enacted similar laws that apply to goods or services covered by the state health care programs and in some cases even private insurance 2017 Community Care Behavioral Health Organization 30

31 Whistleblower Protection Act Purpose: encourage individuals to come forward and report misconduct involving false claims. The False Claims Act (FCA) includes a "qui tam" or whistleblower provision. This provision essentially allows any person with actual knowledge of false claims activity to file a law suit on behalf of the U.S. government. FCA Provisions: protect whistleblowers from retaliation by their employers. Any employee who initiates or assists with an FCA case is protected from discharge, demotion, suspension, threats, harassment and discrimination in the terms and conditions of his or her employment. Whistleblower Entitlements: may be awarded a portion of the funds recovered by the government (typically between 15% and 30%), and reasonable expenses (including attorney's fees and costs for bringing the lawsuit). The FCA also entitles whistleblowers to additional relief, including employment reinstatement, back pay, and any other compensation arising from employer retaliatory conduct against a whistleblower for filing an action under the FCA or committing other lawful acts, such as investigating a false claim, providing testimony, or assisting in a FCA action. Consequences of Misuse: a qui tam action that a court later finds was frivolous may result in liability for fines, attorney fees and other expenses Community Care Behavioral Health Organization 31

32 Federal FWA Laws and Statutes Self-Referral Prohibition Statute (Stark Law): Prohibits physicians from referring Medicaid & Medicare patients for certain designated health services to an entity in which the physician or the physician s immediate family has a financial relationship unless an exception applies. Violations of the law are punishable by a civil penalty up to $15,000 per improper claim, denial of payment, and refunds for certain past claims. Civil Monetary Penalties Law: The Federal Civil Monetary Penalties law covers an array of fraudulent and abusive activities and is similar to the False Claims Act. Violations of the law may result in penalties between $10,000 and $50,000 and up to three times the amount unlawfully claimed. Health Insurance Portability and Accountability Act (HIPAA): Authorized the establishment of the Health Care Fraud and Abuse Control Program (HCFAC) under the U.S. Attorney General and the Office of the Inspector General (OIG). The goal is to coordinate federal, state and local efforts in combating FWA. The U.S. Department of Health and Human Service s (HHS) Office of Civil Rights (OCR) is responsible for enforcing HIPPA privacy and security rules Community Care Behavioral Health Organization 32

33 Deficit Reduction Act (DRA) of 2005 Effective January 1, 2007, the DRA requires all entities that receive $5 million or more in annual Medicaid payments to establish written policies that provide detailed information about: Federal False Claims Act Administrative remedies for false claims and statements Applicable state laws that provide civil or criminal penalties for making false claims and statements Whistleblower protections afforded under such laws Role of such laws in preventing and detecting fraud, waste and abuse in federal health care programs Established the Medicaid Integrity Program: Deficit Reduction Act FAQs: Community Care Behavioral Health Organization 33

34 PA Regulation Resources Record Keeping Requirements PA Code 1101 Regulations MA Bulletin MA Bulletin , , , , Pennsylvania Medical MA Bulletin # Provides general background info on the Bureau of Program Integrity (BPI) and remind providers of the administrative sanctions available to BPI to ensure compliance with applicable regulations. Provides info on the Provider Self-Audit Protocol Applies to all providers enrolled in the Medical Assistance Program Provider Self-Audit Protocol DHS self-audit protocol 2017 Community Care Behavioral Health Organization 34

35 PA Regulation Resources Part III Medical Assistance Manual General Regulations oc.html Payment Regulations oc.html MA Bulletin Drug & Alcohol Facilities Community Care Behavioral Health Organization 35

36 References: Laws and Regulations Federal False Claims Act Statute: 31 U.S.C Anti-Kickback Statute Statute: 42 U.S.C 1320a-7b(b) Safe Harbor Regulations: 42 C.F.R The Exclusion Authorities Statutes: 42 U.S.C. 1320a-7, 1320c-5 Regulations: 42 C.F.R. pts 1001 (OIG) and 1002 (State agencies) Whistleblower Protection Act Physician Self-Referral Prohibition (Stark Law) Statute: 42 U.S.C. 1395nn Regulations: 42 C.F.R Civil Monetary Penalties Law (CMPL) Statute: 42 U.S.C. 1320a-7a Regulations: 42 C.F.R. pt Criminal Health Care Fraud Statute Statute: 18 U.S.C. 1347, 1349 Beneficiary Inducement Law 2017 Community Care Behavioral Health Organization 36

37 Contact Information Ellie Medved Kevin Daugherty Director of Fraud, Waste & Abuse Senior Clinical Auditor/Analyst (Pittsburgh) (Pittsburgh) Todd Jukes, Manager Fraud, Waste & Abuse (Erie) Michael Arnold, Senior Clinical FWA Auditor/Analyst (Moosic) Kristin Levandoski, Clinical FWA Auditor (Moosic) Brad Eckels, Clinical FWA Auditor (Pittsburgh) Darla Becker, Clinical FWA Auditor (Pittsburgh) Camille Luzier, Clinical FWA Auditor (State College) Erin Carpenter, Clinical FWA Auditor (State College) Jean Krochmal, Clinical FWA Auditor (Exton) Mary Timothy, Clinical FWA Auditor (Exton) Lauren Bongiorni, Clinical FWA Auditor (Pittsburgh) Valerie Mininger, Clinical FWA Auditor (Erie) 2017 Community Care Behavioral Health Organization 37

38 Thank you! 2017 Community Care Behavioral Health Organization