North Carolina’s Medicaid Audit Experience September 3, 2013 Presented by: Knicole C. Emanuel 919.981.4031 kemanuel@williamsmullen.com
Why all the Oversight? > The “F” Word 2
What is a RAC? > New und nder er Affo fordab rdable e Care e Act – The e Medicai icaid d RACs s - Recove overy ry Audito itor r Contr ntractor actors > Let’s first understand the Medicare icare RAC program ogram. – States es were re requir quired d to establ ablish ish program ograms s in which ch they y would uld contr ntract act with 1 o or more re Medicai icaid d RACs s by December ember 31, 2010. 2010. – Medi dicaid caid RACs are tasked ed with reviewi ewing ng Medicai icaid d claims ms subm bmitted ted by provi oviders ders of services vices for or which ch payme ment is made de und nder er 1902(a) (a) of the SSA or a waiver er of the State e plan. n. 3
The Four RAC Regions *Source: American Hospital Association 4
RAC Effectiveness in Medicare > RACs s have ve recov covered ered over er $1.03 billion on in overp erpayme ayments. s. (DHHS, OIG “RAC Fraud Referrals”) > CMS estima mates es that the RAC demo monst stra ratio tion program ogram cost sts s approxim proximat atel ely y 20¢ for r each ch dollar ar retur turned ed to the Medi dicare care Trust Funds. (CMS “Evaluation of the Three -Year ear Demonstration”) > Sect ction ion 302 of the Tax Relief ef and d Health th Care re Act of 2006 2006 – Made de the RAC program ogram perm rmanent anent and d requ quired ired nationwide ionwide expan pansion sion by 2010 2010 – Medi dicar care RAC program ogram now w opera eratio tional al nationwi onwide de 5
Relevant Audit Laws > 42 CFR Parts ts 405, 424, 447, 455, 457 and d 498 > Medi dicar care – Recov covery ery Audi dit Con ontra ractors ors (RAC ACs) ) – Program ogram Safeguard eguard Contr ntractors actors (PSC SCs) – Zone ne Program ogram Integ egrit rity Con ontra ractors ors (ZPICs) PICs) > Medi dicaid caid – Medi dicaid caid Integri grity ty Contr ntrac actors ors (MICs) ICs) – RACs 6
Medicaid RACs Program Definit inition ions: s: Medi dicaid caid RAC program ogram means ans a recove covery ry audit dit contr ntractor actor program ogram admini minist stered ered by a S State e to ident entify ify overpaymen rpayments ts and d underpayme derpayments s and d recoup coup overpaymen rpayments. Medi dicare care RAC program ogram means ans a r recovery covery audi dit t contr ontractor actor program ogram admini minist stered ered by CMS to identi ntify fy payme ments s and d overp erpayme ayments nts and d recoup coup overp erpayme ayments. s. 7
RACs in Medicaid > Sect ction ion 6411(a) a) of the Affo fordab rdable e Care re Act expanded anded RAC to Medicai icaid d and d requ quired ired each ch State e to begin in implem ement ntatio ation by Janu nuary ary 1, 2012. 2012. – Ident entificat ification ion of overpaym rpayment nts s and d underpayme derpayments – States es & RAC vend ndor r must t coo oordina rdinate te the recov covery ery audi dit t effort forts – RAC vendors dors reimb mburse rsed d thro rough ugh con onting ingency ency model del 8
Why RACs? (Do We HAVE to?) > On Septemb tember er 16, 2011, the federal deral Cent nters ers for r Medi dicare care & Medi dicaid caid Services ices (CMS MS) ) pub ublished shed the Final al Rule for Medicai icaid Recovery very Audit it Contract actor ors s (RAC) C). > Und nder er the Medicai icaid d RAC program ogram, , States s must st enter er into con ontra racts s consi nsist stent ent with State law in accord cordance ance with 42 CFR FR subp bpart art F w F wit ith one e or more re eli ligi gibl ble e Medicai icaid d RACs s to perf rform rm post st-paym payment ent audi dits s in ord rder er to ident entify ify Medicaid icaid payme ments s that may have e been en und nderpaid erpaid or overpaid rpaid. . > RACs s must st follow low feder deral al and d state guidel delines ines to recov cover er overp erpayme ayments nts or info form rm the N.C. Division on of Medical ical Assist istance ance (DM DMA) A) of under nderpayments. payments. 9
MEDICAID RACs 10
RAC Audits: Key Issues > Thre ree-year ear look ok-back ack period riod > Registere tered nur urses ses or thera rapist sts s are requir quired ed to make e determin erminatio ations s regardi arding ng medical dical necessi cessity, and d cert rtifi ified ed cod oders ers are requ quired ired to make cod oding ng determ erminat inations. ions. > RACs s are e not entit itle led to keep p their ir cont ontingency ingency fees s if if a deni nial al is overt erturned urned on appeal. peal. > Appea peal Rights, s, 42 CFR 455.13 455.13 11
NC New Medicaid Auditors > Publ blic ic Consu nsulting lting Grou oup p (PCG) CG) – October tober 2012 – Fee For r Serv rvice ice Claims ms > HMS – Octobe tober r 2012 – inpatie atient nt and d outpat tpatient ient hosp spital al, , long-term erm care, e, laborat oratory, ory, x-ray ay and d speci ecial alize ized d outpat tpatient ient thera erapy py claims ms 12
Public Consulting Group 13
Public Consulting Group > Publ blic ic Consu nsulting lting Grou oup p (PCG) CG) provi ovides des indu dust stry ry-leading leading manag nagement ement con onsul sultin ting g and d techn hnolog logy y to help p pub ublic ic sector tor edu ducat cation ion, heal alth, th, hum uman an servic vices, es, and d other er go government ernment cli lient ents s achi hieve eve their ir perf rforma rmance ce go goals ls and d better er serv rve e pop opul ulatio ations s in need. ed. 14
Tentative Notice of Overpayment 15
Tent ntative ive Not otic ice of of Ov Overpaym payment ent Valid sample of your Medicaid paid claims for dates of service from 11/1/2009 to 4/40/2009 16
Extrapolation $23,462.40 $418,024.00 17
Extrapolation $13,442.58 $702,611.00 18
Key Issues in TNO > Samp mple e Size (Usu sual ally y over er 100) > Payabl able e Imme medi diatel ately > Appea peal: – Extrapolation? – Audit? – Informal? – Office of Administrative Hearings? 19
Have PCG Audits Been Accurate? Ex Examp mples les of PCG Blund nders ers: From om Real Life e Ex Experien erience 20
Top 10 PCG Bloopers This is my opinion from my personal experience. It in no way is purporting that these bloopers are occurring in New Mexico, because I do not know. This in no way is an attempt to disparage PCG. Again, these examples are from my own experience. 21
Number 1: Wrong Policy 2008 2008 2013 2013 Enter the at atten ending ding Enter the atten ending ing provider’s NPI for the provider’s NPI for the individual dentist individual dentist rendering service. (This rendering service. (This number should ld number must correspond correspond to the to the signature in field signature in field 53.) 53.) 22
Number 2: Canned Requests http:/ p://www www.wr .wral.com/news/local/v al.com/news/local/video/12 ideo/1220 2011 1117/ 17/ 23
Number 3: No Training > Bache chelor' lor's s degree gree in any field > Two+ o+ years rs paid d experience erience work rking ing with critic tical al care re provider oviders, s, pub ublic ic heal alth th provi oviders, ders, or providers… > One e year r of the experience erience must t have ve in includ luded ed provider ovider monit nitorin oring, g, Medi dicaid caid or third d part rty y payer er provi ovider der billing, g, or provi ovider der trainin ining > One e year r of the experience erience must t have ve been en in in a home me heal alth th pro rogram gram, , com ommu munity y health lth program, ogram, hosp spital al, , privat vate e pract actice, ice, pub ublicly icly-fund funded ed institution… > Audi diting ing experi perien ence ce a plu lus > Publ blic ic sector tor experience erience a plus 24
Number 4: No Communication > Prov ovider: ider: I am calling ng to try to find d out why PCG determin ermined ed all these se claims ims were re non oncomplia compliant. nt. > PCG: : Refer er to DMA websi bsite, e, policy cy ___. > Prov ovider ider: Ok. Bu But what at about out Medi dicaid caid Recipient ipient A, DO DOS X. We followed lowed the policy icy. > PCG: : Refer er to DMA websi bsite, e, policy cy __. 25
Number 5: That’s Not Required! > Denial: ial: No prior ior authori horizatio ation. > Outpat tpatient ent Behavi avioral oral Thera erapy py (OBT) BT) allows ws 16 unma managed naged visits for r children. dren. > PCG reviews ews an unma managed naged OBT visit (no no prior ior auth is requir quired ed) ) and d holds lds claim m non oncompl ompliant ant for r lack of prior ior auth ….WHAT? 26
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