Thank you For inviting the Office of the Medicaid Inspector General to speak today. 1
Today s Agenda 2013 14 OMIG Work Plan Integrity Takes Effort By All Parties Conclusion MISSION STATEMENT Our mission is to enhance the integrity of the New York State Medicaid program by preventing and detecting fraudulent, abusive, and wasteful practices within the Medicaid program and recovering improperly expended Medicaid funds while promoting high quality patient care. 2
We Have A Statewide Presence Regional Offices: Capital District Buffalo Rochester Syracuse Westchester New York City (2) Long Island We Get Results We produce a significant number of audit reports: 1,659 final audit reports in our last reporting year. We trigger hundreds of millions in collections: $410 million in our last reporting year. We prevent billions from going out the door: Educating providers through compliance updates, webinars, and public speaking. 3
Case in Point: Social Adult Day Care You may have read articles in the New York Daily News and The New York Times two weeks ago concerning social adult day care in the metropolitan New York City area. Well before any reporter was looking into this, OMIG had included this issue in our Work Plan (page 4), and had been investigating the relationship between social adult day care and managed long term care plans. Social Adult Day Care (continued) Based on the federal complaint, OMIG issued a Notice of Immediate Agency Action (NOAA) (April 15, 2013) in a recent case involving social adult day care in metropolitan New York City. 4
2013 14 OMIG WORK PLAN 6/5/2013 9 2013 14 Work Plan OMIG s active Business Line Teams (BLTs) focus on areas of interest to LeadingAge NY members: Residential Health Care Facilities Home and Community Care Services Physicians, Dentists, and Laboratories Pharmacies and Durable Medical Equipment Transportation 5
Residential Health Care Facilities Covers nursing facilities and assisted living programs Initiatives for nursing facilities include: Base year audits Rate appeals Monitoring inappropriate use of atypical antipsychotics (in conjunction with Pharmacies and Durable Medical Equipment BLT) Base Year Audits Example of Recent Base Year Audit (January 2013): Elmhurst Care Center, Inc. (Buffalo): $1.638 million Non base year expenses Working capital interest expenses overstated Organization/start up costs duplicated Full audit is posted on OMIG s Web site 6
Rate Audit Example of Recent Rate Audit (April 2013): Elderwood Health Care at Oakwood (Williamsville): $619,427 Overpayments ranged from $1.21 to $2.43 per day Audit also covered adjustments to mortgage interest and amortization adjustments, return on real property equity disallowances, and return on average equity disallowances Open BLTCR appeals worth $194,917 in the facility s favor were processed by OMIG resulting in a net overpayment of $424,510 Full audit is posted on OMIG s Web site Antipsychotics in RHCFs On March 6, 2013, OMIG and the Department of Health sent a joint letter to all nursing home administrators, warning that the inappropriate use of these medications in elderly demented individuals is a significant resident safety issue that requires your immediate attention. 7
Antipsychotics in RHCFs (continued) DOH nursing home surveyors are trained and responsible to complete quality reviews for unnecessary medications with an increased focus on, and awareness of, the use of antipsychotic medications. The CMS initiative is aimed at reducing the usage of unnecessary antipsychotic drugs by no less than 15 percent. The good news: We saw a reduction. The bad news: We still have a way to go. Further Initiatives for Nursing Facilities (continued) Dropped ancillary services Notice of rate changes (rollovers) Bed reservations Clinical audits of patient review instruments (PRIs) Reviews of minimum data set (MDS) submissions Review of reported RHCF capital costs Medicaid Rate Part B offset reviews 8
Initiatives for Assisted Living Programs OMIG will review costs associated with Assisted Living Program (ALP) providers to ensure that costs are aligned with regulations, and that proper documentation is in place. Inappropriate fee for service billings for ALP residents Fee for service reviews of ALP resident care Home and Community Care Services This BLT covers five program areas: Certified home health agencies (CHHAs) Long term home health care programs (LTHHPs) Personal care aides (PCAs) Traumatic brain injury (TBI) programs Private duty nursing (PDN) services 9
Home and Community Care Services (continued) All five programs CHHA, LTHHCP, PCA, TBI, PDN will see audits that will examine the following issues: Provision of services Consistency with patient care plans/service plans Home and Community Care Services (continued) Spend down reviews Improper billing for inpatients and nursing facility residents Dual eligibles 10
Home and Community Care Services (continued) LTHHCP and CHHA Rates: CHHA Conflict and Exception Reporting Episodic payment system (EPS) for CHHAs Home and Community Care Services (continued) Home and Community Care protocols are posted on OMIG s Web site. So are CHHA protocols 11
Episodic Payments Effective May 1, 2012, DOH implemented an episodic payment system (EPS) for CHHA providers for services provided to Medicaid patients receiving home care. This is: Based on prices for 60 day episodes of care, adjusted for patient acuity and regional wage differences Monitored via edits placed on number of service units per revenue codes, enacted in September 2012 Physicians, Dentists, and Laboratories The Physicians, Dentists, and Laboratories BLT will impact this group as well: Dental review: OMIG will audit dentists to ensure that they are billing RHCFs and ALPs for what is covered in the rates and not direct billing Medicaid Excluded providers: OMIG will match excluded provider lists from the Centers for Medicare & Medicaid Services (CMS), as well as OMIG s own, to ensure that excluded providers are not billing the Medicaid program 12
Pharmacy and Durable Medical Equipment The Pharmacy and Durable Medical Equipment BLT is concerned with: Use of atypical antipsychotics, a class of prescription drugs used for the treatment of schizophrenia and bipolar disorder. Also, when used in off label situations, these medications have a high risk of death for individuals with dementia who receive them to control behavior. OMIG will review the use of these prescriptions in RHCFs. Pharmacy and Durable Medical Equipment (continued) Durable medical equipment: OMIG will verify that DME claims in RHCFs and ALPs are appropriately billed in accordance with Medicaid regulations. DME providers are evaluated for enrollment based on need in the area. OMIG looks at the density of providers in the geographic area to determine need. OMIG also does site visits on potential enrollees to the program to ensure that DME providers meet criteria. 13
Transportation Claim review and investigation: OMIG will review and investigate claims for transportation services to verify whether the services were provided and were medically necessary. Transportation system match: OMIG will continue the system match initiative, which looks at transportation providers who used disqualified drivers. Protocols Available for Review We also have two fee for service transportation protocols posted: Transportation ambulette Transportation taxi/livery 14
Recent Case: $4 Million Audit On May 6, OMIG issued a final audit to Alert Ambulette in Brooklyn, focusing on transportation problems. Most of those issues were: Missing/inaccurate information on Medicaid claims, including no driver s license numbers or vehicle license plate numbers Driver not licensed by the New York City Taxi and Limousine Commission OMIG Cost Recovery Activities Self Disclosure: OMIG encourages providers who discover overpayments to investigate and report matters that involve possible fraud, waste, abuse, or inappropriate payments that they identify through self review, compliance programs, or internal controls, to report those directly to OMIG. External audits by outside agencies: OMIG will continue to assist external agencies in their audits of the Medicaid program, and assure that proper corrective action is taken on any audit findings. 15
Cost Saving Activities Prepayment Review: Areas of activity include: Dual eligible (Medicare/Medicaid) Consumers in the cancer treatment program Private duty nurses CHHAs and home health agencies Misuse of National Provider Identifiers (NPIs) as a prescribing, referring, or servicing provider DME claims submitted with no diagnostic code Third Party Activities Estate and casualty recovery: OMIG is working with counties and the Department of Health to centralize estate and casualty recoveries, as specified in Medicaid Redesign Team initiative 102. Pre payment insurance verification: By identifying third party coverage and updating the third party file on emedny prior to making payments through Medicaid, claims on the Medicaid program are rejected until third party resources are utilized. 16
INTEGRITY TAKES EFFORT BY ALL PARTIES 6/5/2013 33 Resources To Help You Improve Everyone has heard that an ounce of prevention is worth a pound of cure. We know that providers are working on their compliance efforts. OMIG has added more resources into our compliance efforts: Expanded the Bureau of Compliance Added new resources to the Compliance Library on OMIG s Web site (www.omig.ny.gov) Dedicated e mail address: compliance@omig.ny.gov Dedicated phone number: 518 408 0401 17
More Transparency Than Ever Before As of today, OMIG has posted more protocols than ever before with 14 protocols on our Web site. The one of most interest to this group is for certified home health agencies (CHHAs). OMIG Improves Its Web Site OMIG has a new customercentered Web site: Specific provider section with one stop shopping. Exclusion checks right up front Faster response time the page loads quicker 18
OMIG Improves its Compliance Web Information OMIG s has developed tools for providers to help improve compliance efforts. Our Improved Compliance Section: Has certification information. CIAs Revised Compliance Library. Conclusion 6/5/2013 38 19
Reaching Out OMIG continues to work with providers on compliance education and developing useful tools exchange of ideas is important Bottom line: improper payments must be recovered and returned to the Medicaid program How You Can Work With Us 40 20
We Want to Hear from YOU Our new, improved Web site: www.omig.ny.gov Join our Listserv Follow us on Twitter: @NYSOMIG Like Us on Facebook, Google Plus Dedicated e mail: information@omig.ny.gov More than 4,500 final audit reports Audit protocols And much, much more! Contact Information James C. Cox Medicaid Inspector General New York State Office of the Medicaid Inspector General 800 North Pearl Street Albany, NY 12204 518 473 3782 21