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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Thank you
For inviting the Office of the Medicaid Inspector General to speak today.
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Today’s Agenda
2013‐14 OMIG Work Plan
Integrity Takes Effort By All Parties
Conclusion
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
We Have A Statewide Presence
Regional Offices:
Capital District
Buffalo
Rochester
Syracuse
Westchester
New York City (2)
Long Island
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
We Get Results
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
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2013‐14 OMIG WORK PLAN
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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)
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Rate AuditExample 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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.”
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Home and Community Care Services (continued)
Spend down reviews
Improper billing for inpatients and nursing facility residents
Dual‐eligibles
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Home and Community Care Services (continued)
LTHHCP and CHHA Rates:
CHHA Conflict and Exception Reporting
Episodic payment system (EPS) for CHHAs
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Home and Community Care Services (continued)
Home and Community Care protocols are posted on OMIG’s Web site.
So are CHHA protocols
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
Protocols Available for Review
We also have two fee‐for‐service transportation protocols posted:
Transportation ambulette
Transportation taxi/livery
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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.
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INTEGRITY TAKES EFFORT BY ALL PARTIES
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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: [email protected] Dedicated phone number: 518‐408‐0401
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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).
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
OMIG has a new customer‐centered Web site:Specific provider section with one‐stop shopping.Exclusion checks right up frontFaster response time – the page loads quicker
OMIG Improves Its Web Site
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
OMIG’s has developed tools for providers to help improve compliance efforts. Our Improved Compliance Section:Has certification information.CIAsRevised Compliance Library.
OMIG Improves its Compliance
Web Information
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Conclusion
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
How You Can Work With Us
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Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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: [email protected]
More than 4,500 final audit reports
Audit protocols
And much, much more!
Fighting Fraud. Improving Integrity and Quality. Saving Taxpayer Dollars.
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