Lesson ons Learned: OIG/ HHS and State Sponsored Medicaid Audits Target: : Behaviora oral Health Services July 15, 2014 Prepared for the Council by Susan Dess, RN, MS Crestline Advisors 1
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Purpose Recent Federal OIG BH Audits – NJ, WI, NY, MO, State-Sponsored Audits- CA, NM Recovery Audits AZ Specifics CMS Regulations, Expectations, etc. Audit processes Regulatory Changes Compliance Best Practices Medical Necessity Implications to Arizona Providers and Readiness Additional Information Questions 3
Provide perspective and context to recent OIG 1. and State Medicaid BH audit findings Specify the three aspects of compliance audits 2. Present the risks associated with each aspect 3. Identify the steps necessary to decrease risks 4. 4
OIG 2014 WORK PLAN & FEDERAL MEDICAID AUDITS 5
They’re Coming……………… Pack Your Boxes 6
Target Audits: Medicaid ◦ Atypical antipsychotic drugs for children ◦ Inappropriate dispensing of Opioids ◦ Continuing day treatment mental health services ◦ Transportation services ◦ Questiona nable e billing for OP mental health h servi vices es ◦ State reporting of Medicaid collections ◦ SAMHSA reporting and oversight of grant program performance Target Audit: Medicare ◦ Mental Health Providers – Medicare enrollment and credentialing (new) http://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf 7
Audit A-02-12-01009/released 12-24-13 o Most of New Jersey’s Claims for Supported Employment Services for a 37 month period were non allowable (Community Care Waiver Program) Major Finding/CMS Recommendation o Medicaid division and most providers did not ensure that supported employment services were documented or provided by approved personnel to eligible beneficiaries o State required to refund $6.9 M to Federal Government http://oig.hhs.gov/oas/reports/region2/21201009.asp12-24-2013 8
Audit A-05-07-00036 / released 9-11-13 o Most of Wisconsin’s Claims for Residential Care Center (RCC) payments did not comply with Federal requirements o Of the $24 million Federal share $22.8 million Federal share) was unallowable Major Findings/CMS Recommendation o RCC payments contain treatment services provided by youth care workers and social workers that could be claimed as "other services" under the State's Medicaid Early and Periodic Screening, Diagnostic, and Treatment program, known as HealthCheck. o Refund $22.8 million to the Federal Government for unallowable RCC costs claimed under HealthCheck o Work with CMS to identify payment and allocation methodologies for claiming allowable Medicaid RCC costs under HealthCheck http://oig.hhs.gov/oas/reports/region5/50700036.pdf 9
Audit A-02-11-01038 / released 9/5/13 o Continuing day treatment (CDT) services provided by hospital- based providers were not in accordance with Federal and State requirements. o CDT services include assessment and treatment planning, discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy, among others. ▶ Major Findings/ CMS Recommendation o Certain hospital-based CDT providers did not comply with Federal and State requirements o DOH did not ensure that the State Office of Mental Health (OMH) adequately monitored the CDT program, monitoring required o Refund $8.3 million to the Federal Government http://oig.hhs.gov/oas/reports/region2/21101038.asp 10
Audit A-05-12-00050 / released 6/21/13 o $$21.4 million of the total $22.7 in Federal reimbursement for Medicaid inpatient psychiatric service and disproportionate share hospital (DSH) payments made to Hawthorn Children's Psychiatric Hospital (Hawthorn) for claims with dates of service, July 1, 2005, through June 30, 2010 was not claimed in accordance with Federal requirements for inpatient psychiatric hospital services ▶ Major Findings/CMS Recommendations o The provider must demonstrate compliance with the basic Medicare Conditions of Participation (CoP) applicable to psychiatric hospitals and Hawthorn did not demonstrate compliance with the special Medicare CoP during the audit period o Refund $21.4 million to the Federal Government o Identify and refund the Federal share of any additional payments made to Hawthorn for claims with dates of service after the audit period http://oig.hhs.gov/oas/reports/region5/51200050.asp 11
T, T, T ◦ Themes? ◦ Trends? ◦ Thoughts? 12
STATE SPONSORED AUDITS- CA, NM 13
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July 2013 - DHCS Audits and Investigation Division launched a statewide review of all addiction providers receiving Medi-Cal funding August 2013 - Medicaid Payments to 46 Addiction Treatment Clinics and 62 satellite counseling sites with-held Result -16 clinics referred to DOJ . 15
‣ Provision of services not deemed medically necessary. ‣ Billing California’s Drug Medi-Cal (DMC) program for services that were not rendered. ‣ Hiring addiction treatment counselors on the federal list of excluded entities and individuals. ‣ “Copying and pasting” re -assessments, goals, progress notes from one year ‣ One BHMP approved services at 19 Los Angeles- area rehab clinics with more than 1,800 patients and never met most of them. ‣ Other medical directors caught approving fraudulent care or were accused of negligence by the state medical board. 16
Medi-Cal launching an overhaul of its drug rehabilitation program The Department of Health Care Services pledged a multitude of changes including tightening rules through emergency regulations and using an “elite strike team” to detect fraud by mining data. The department also will ask the federal government for permission to more radically refashion Drug Medi-Cal, part of the nation’s largest Medicaid system. The report made public an internal audit that identified weak rules, dysfunctional bureaucracy and ineffectual monitoring that left the publicly funded rehab program for the poor open to fraud and put patients at risk. http://cironline.org/reports/medi-cal-agency-overhaul-drug-rehab-program-after-critical-audit-5777 17
A pattern of serious concerns were identified by the state’s BH Collaborative in early 2012. Deficiencies persisted for several years, but were identified through OPTUM BH of New Mexico’s implementation of a new software system OPTUM notified the state’s Human Services Division, who informed the New Mexico State Attorney’s Office NM contracted with an auditor 18
Public Consulting Group (PCG) audits ensued CMS was notified of results Medicaid funds for 15 BH agencies were frozen 15 agencies referred to NM Attorney General 13 Agencies were transitioned to 5 AZ BH providers 2 Agencies were fined and given technical assistance by AZ providers 19
Under the Affordable Care Act (ACA), states have more power to suspend payments whenever there is credible evidence that Medicaid dollars are being misused ◦ States are expected to take sweeping action, “ unless there is good reason not to.” ◦ “Authority is designed to stop taxpayer dollars from going out the door when there’s a credible allegation of fraud.” ◦ Investigators and prosecutors have expanded latitude 20
Fraud allegations were based on the following review components: Clinical Case File Audit ◦ Case file documentation, staffing qualifications and credentials IT/Billing Systems Audit ◦ Billing systems and the protocols and processes employed Enterprise Audits ◦ Organizational structure, key stakeholders, third party contracts, and other stakeholder relationships 21
Average error rate of 57.1% for 15 high volume providers representing 85% of state’s Medicaid BH spend Significant levels of non-compliance with state payment rules and regulations Poor documentation practices Lack of safeguards against overbilling Deficiencies in accuracy of clinical documentation Quality of Care concerns 22
Software company prevented reviewers from sharing system manuals Lack of audit trail for the creation of and changes made to claims records in provider billing systems Lack of audit trail for any changes made to the 837 reports prior to finalizing Automated Clearing House portal 23
Poor Quality Management Lack of identified Compliance Officer Compliance Officer not reporting to BOD Lack of compliance oversight by BOD Billing code selection or direction by billing department Duplicative billing of funding streams Conflicts of Interest not identified by BOD 24
Cross billing at different locations at same time Cross billing multiple codes and double billing (individual and group therapy at same time) Uncertainty as to who rendered services Billed units did not match units documented on progress notes Copying and pasting of progress notes Up-coding of individual therapy Excessive billing for psychosocial rehab Forging clinical records to incorporate more time than truly performed Billing of OP services the same day as bundled services 25
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