Division of Audit and Program Integrity

Division Chief: Eugene ( Gene) Grasser

Program Integrity provisions of Patient Protection and Affordable Care Act Recovery Audit Contractor (RAC) Coordinate administrative remedies under Tennessee False Claims Act with TN Attorney General

Office of Audit/Investigation: Vicki Guye

Conduct Internal/external audit Perform Desk/field investigations Deficit Reduction ACT (DRA) compliance Coordinate Payment Error Rate measurement (PERM) Electronic Health record (HER) verification and audit

Office of Program Integrity: Dong Siegel

Surveillance and Utilization Review (SURS), claim/encounter based data mining Track fraud referrals (recipient and provider)Maintain Provider Fraud Task Force (PFTF) database Managed Care Contractor program integrity compliance Liaison with CMS Medicaid Integrity Group (MIG) & Medicaid Integrity Contractors (MIC)RAC coordination

CMS: Center for Program Integrity

Medicaid Program Integrity Provisions

Presentation based on new Medicaid Program Integrity provisions of HR 3590 – Patient Protection and Affordable Care Act

Some final regulations have been issued by CMS ( Provider Enrollment and Screening – 2/2/11) and others are still in the NPRM status (RAC -11/10/2010)

CMS has also issued clarifying State Medicaid Letters

Letters to State Medicaid Agencies –

Preliminary Guidance on CMS Website

Medicaid Program Integrity Provisions – Section 6401 Provider Screenings and Enrollment Requirements - Medicare

Medicaid Screening Process Must Parallel Medicare

Medicare and Medicaid Screening provisions are not applicable to providers enrolled in Part C Medicare managed care plans or Part D Medicare drug plans or Medicaid Managed Care Plans

Medicare requirements for New Providers

Level of Screening - Depends on classification of provider

Limited: individual practitioner, hospital, ASC , FQHC,SNF,..

Moderate: Ambulance, CMHC, CORF, hospice, …

High: newly enrolling HHA & DME

Medicaid Program Integrity Provisions – Section 6401

Provider Screenings and Enrollment Requirements - Medicare

Medicare (Medicaid) requirements for each Level

Limited: exclusion database checks, license verification, disclosure

Moderate: Limited level plus: additional on-site visit

High: Moderate level plus: criminal background checks, fingerprinting, unscheduled and unannounced site visits

Required Enrollment and Screening Application Fees

2010 - $500 and adjusted for inflation

Providers are only required to pay one fee per enrollment period to Medicare or a state Medicaid program

Medicaid Program Integrity Provisions – Section 6401

Provider Screenings and Enrollment Requirements - Medicare

New Providers - Medicare

Provisional Period – 1 Year Enhanced OversightPrepayment review , Payment caps, etc.

Increased Disclosure – Affiliations on Disclosure - Reasons to Deny Enrolment

Uncollected Overpayments

Suspension or Revocation of Billing Privileges Medicare or Any State

DHHS Secretary may Issue Temporary Moratoriums on Enrollment if necessary for F&A issues & States may request a state moratorium

Medicaid Program Integrity Provisions – Section 6401

Provider Screenings and Enrollment Requirements - Medicare

Current Providers – Medicare

Revalidation of Enrollment

Starting 180 days after passage

Procedures apply to providers within two years of enactment

Within 3 years of Enactment - No providers will remain without revalidation

Medicaid Program Integrity Provisions – Section 6401

TennCare MCO Provider Enrollment and Screening Requirements

Although Providers in TennCare MCO’s will not be subject to the new enhanced Medicare & Medicaid Fee For Service provider Enrollment and Screening Requirements, TennCare MCO’s must continue to perform the following enrollment procedures, as well as, Provider Credentialing and getting a TennCare ID# for the provider in addition to any additional requirements mandated by the MCO’s internal rules and procedures

Collect Basic demographic informationCollect W-9 form (taxpayer ID)Verify NPI numberRequire submission of Disclosure of ownership & control informationVerify License Collect SSN #Check against: HHS OIG exclusion list

Tax delinquencyDeath file

Request a TennCare Provider number prior to reimbursing the provider

Medicaid Program Integrity Provisions – Section 6401

Increased Disclosure RequirementsWho Medicaid providers, fiscal agents and managed care entities

What1. Name and address of individual or corporation with ownership or control interest2. Date of birth and SSN for individual3. Other Tax information corporation with ownership & control and subcontractor in which

the disclosing entity has a 5% interest 4. Information must be provided whether the person with ownership is related to another

person with ownership or control in the disclosing entity or whether the person or entity with the ownership or control interest in a subcontractor has a 5% or more interest is related to another party with ownership or control in the disclosing entity

5. Name, address, DOB, & SSN of managing employees of disclosing entity 6. Medicaid/Medicare convictions and/or exclusions

When Providers: 1. Submitting application, 2. Request by Medicaid & 3. Ownership change

Fiscal Agents & MCO’s: 1. RFP proposals, 2. Execute Contract, 3. Renewal & 4. Ownership Change

*Disclosure is also required by TN statue: T.C.A.71-5-137 & T.C.A.8-50-502

Medicaid Program Integrity Provisions – Section 6402

Data matching - Integrated Data Repository a data repository Medicare (A, B, and C &D), Medicaid, CHIP, VA, DOD, SSI, IHS, etc.

Beneficiary in Health Care Fraud Scheme - Administrative Remedy for Knowing Participation by a Beneficiary in Health Care Fraud Scheme will be assessed against enrollees that participated in health care schemes.

*TN Statute T.C.A.71-5-2601 also makes certain actions of this type a Class E Felony

National Provider Identifier - January 2011 Requires all providers and suppliers that qualify for a national provider identifier to include this identifier on all applications for enrollment.

Medicaid Statistical Information System (MSIS) - Permits the withholding of federal matching payments for states that fail to report enrollee encounter data.

Permissive Exclusions - Allows permissive exclusions for individuals or entities that knowingly make false statements or misrepresentations of material facts.

Medicaid Program Integrity Provisions – Section 6402

Deterrence/Civil and Criminal Penalties - Amends the Anti-Kickback statute so that a claim that includes items or services violating the statute would also constitute a false or fraudulent claim. These CMP’s can be up to $50,000 or up to 3 times the amount of the claim for each item or service for which the payment was made based on the application containing the false statement or misrepresentation of a material fact.

Subpoena Authority - Grants the Secretary subpoena authority in exclusion-only cases. The DHHS OIG will be given subpoena authority.

Medicare and Medicaid Integrity Programs - Requires entities that are enrolled in Medicare and Medicaid to submit performance statistics on the number of fraud referrals, overpayments recovered, and return on investment. (Sec. 6402 of H.R. 3590)

Section 6402 – Overpayments A provider, supplier, Medicare Part C or Part D plan and Medicaid managed care plans must report and return overpayments to Medicaid with 60 days of their identification or be subject to the Federal False Claims Act. MCO’s were notified in March 2011 and tasked to notify providers.

Medicaid Program Integrity Provisions – Section 6402

Suspension of Payments for a Credible Allegation of Fraud

455.2 - Definitions - May be verified from any source but not limited to: 1. Fraud hot line

2. Claims Data mining2. Patterns from provider audits, civil false claims, law enforcement

investigation with an indicia of reliability which has been reviewed by Medicaid

455.23 – 1. Agency must suspend after determining a credible allegation of fraud for which there is an investigation pending unless good reason not to

suspend 2. May suspend without first notifying 3. Provider may request and must be granted administrative review 4. Within 5 days of suspension unless requested not to by law enforcement 5. Within 30 days if law enforcement requests not to notify 6. Suspension is temporary and will not continue if Agency or prosecuting authority determines insufficient evidence or legal proceedings of alleged fraud are completed.

Medicaid Program Integrity Provisions

Section 6403 - National Practitioner Data Bank

DHHS will maintain a national fraud and abuse data bank for reporting adverse actions against providers.

Section 6411 – Recovery Audit Contractor (RAC)

By 12/31/2010 states shall contract with a contingency fee based RAC.

NPRM issued on 11/10 2011

TennCare’s competitive procurement selected HMS as Medicaid RAC

Contract effective 2/1/2011 and is being implemented

Section 6501 - Termination of Provider participation

States shall terminate any individual or provider that has been excluded from Medicare or another state.

Medicaid Program Integrity Provisions

Section 6502 – Medicaid Exclusion from Participation

Requires State Medicaid agencies to exclude from participation for a period any entity that has unpaid overpayments, is suspended or excluded from participation or is affiliated with an entity suspended or excluded.

Section 6503 - Required Registration under Medicaid

Requires agents, clearinghouses or alternate payees to register.

Section 6505

Prohibits paying for services to institutions located outside the US.

Recovery Audit Contractor

Introduction

In accordance with Section 6411 of the Patient Protection and Affordable Care Act, TennCare issued an RFP, HMS, was selected with an effective date of February 1, 2011. A required Medicaid State Plan Amendment was submitted.

Reimbursement

The RAC contractor will be funded on a contingency fee basis and only receive reimbursements from recovered funds in accordance with 42 CFR 455.510. Funds will only be considered recovered at the conclusion of any and all appeals available to the provider pursuant to TennCare Rule 1200-13-18.

Coordination of PI efforts between TennCare, the MCOs and the RAC

All Potential RAC recoveries must be presented to TennCare OPI for review.

The RAC will not be allowed to pursue a recovery for a provider & issue previously identified by an MCC, TennCare or law enforcement.