Earn CEU credit Meet Greg Burkhart see insert Using adult learning - PDF document

Volume Ten Number Seven July 2008 Published Monthly Earn CEU credit Meet Greg Burkhart see insert Using adult learning Chief Compliance & Ethics Officer Sentara Healthcare styles in compliance page 14 education page 9 Also: Hospitals hit hard in Feature Focus: OIG’s Open Letter on the recent government Self-Disclosure Protocol enforcement actions page 46 page 52

Health Care Compliance Association • 888-580-8373 • www.hcca-info.org July 2008 Editor’s note: Heather O’Shea is a Partner in the health care practice of Jones Day in Chicago. Heather may be reached at hoshea@jonesday.com. Keri Tonn is an associate at Jones Day in Dallas. Keri may be reached at kltonn@jonesday.com. New York State Medicaid Work Plan: A sign of the times? By Heather O’Shea, Esq. and Keri Tonn, Esq. HEATHER O’SHEA the work; nine agencies (including the Attorney General’s Medicaid Fraud Control Unit, and 13 counties that are participating in OMIG dem- onstration projects) are specifjcally identifjed in the Work Plan. Tiis type of interagency col- laboration has traditionally been more common on the federal level. O n April 18, 2008, New York’s cally, OMIG will review the claims to ensure Office of the Medicaid Inspector Tiere are similarities between the New York that there was no inappropriate bundling. General (OMIG) issued a detailed Work Plan and that of the Department of Work Plan (the Work Plan) specific to the Health and Human Services, OIG annual Work OMIG will also audit physicians who have state’s Medicaid program. 1 New York is the Plan, including the general format and certain ordered high volumes of controlled substances first state to publish an individual state Work focus areas, but providers and suppliers should that are covered by Medicaid. In connection Plan of such a detailed and comprehensive know that this is not the “same old, same old.” with this review, OMIG intends to conduct nature. Given the obligations imposed by Tie New York Work Plan identifjes a number of a chart review to determine if documentation the Deficit Reduction Act of 2005, it is new target areas that OMIG intends to scruti- supports medical necessity. likely that many states will take notice, nize. Perhaps the most signifjcant new focus area possibly even follow New York’s lead, and is managed care. Tie Work Plan lists more than Tie pharmacy review will focus on claims infor- perhaps even use the Work Plan as a model. 20 specifjc areas related to Medicaid managed mation and comparing that documentation to the Consequently, compliance officers, regardless care that OMIG intends to review. Some of the actual prescriptions. In addition, OMIG will con- of the state in which they are located, should focus areas include payments for deceased en- duct a review of selected out-of-state pharmacies review the Work Plan and consider incorpo- rollees, payments for enrollees who moved out that bill New York State Medicaid to determine rating applicable focus areas into their orga- of state, stop loss payments, and improper cross- whether the pharmacies are properly dispensing nization’s audit plans and risk assessments. over/duplicate payments. OMIG also intends to and delivering medications. In connection with review data matches where there is no encounter the pharmacy reviews, OMIG also intends to Overview of the New York Work Plan data for newborns, but where Medicaid has paid verify the licenses of all ordering providers in an Tirough its Work Plan, OMIG has provided monthly capitation payments. Tiis review will efgort to detect fraudulent practices, such as stolen a detailed description, often with the support- focus on identifying incorrect payments and provider ID numbers, unlicensed physicians, and ing authority, of the specifjc areas of review addressing quality-of-care issues. excluded providers who prescribe drugs. of the Medicaid program for state fjscal year 2008-2009 (April through March). Tie Work Some other areas in the Work Plan focus on The New York Work Plan also devotes atten- Plan is ambitious, wide-ranging, and will require laboratory services, physicians’ prescription tion to the usual targets. Five audit areas are technical expertise to execute. Tie state appar- ordering practices, and pharmacy providers. applicable to hospitals. OMIG will: ently recognizes this fact and has earmarked OMIG will review Medicaid payments for n Perform reviews designed to detect provid- funds for up to 750 stafg and has set aside ad- some independent laboratories. OMIG plans ers that are upcoding. ditional resources for investments in technology. to review a sample of claims to determine n Examine ambulatory surgical services to de- Additionally, the New York Medicaid Inspector whether the tests were ordered, that the results termine whether the services were provided General has announced his intentions to col- were available, and that the laboratory billed in in the appropriate setting. One focus of this laborate with other state agencies to carry out accordance with applicable regulations. Specifj- review is to determine whether the service 54