pi presentation for provider services workshop 5.18.15 · physician self-referral (stark law)...

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Hello. The purpose of the training is to present a general overview of Medicaid fraud, waste and abuse and program integrity measures. 1

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Page 1: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Hello.  The purpose of the training is to present a general overview of Medicaid fraud, waste and abuse and program integrity measures. 

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Page 2: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Fraud, waste and abuse divert significant resources away from necessary care that is covered by Medicaid program rules.  Every year, Medicaid processes 3.9 billion claims, representing $430 billion paid annually for more than 57 million clients enrolled in 56 state and territory administered programs. Preliminary client numbers for 2014 indicate enrollment has risen to 63 million due to the Affordable Care Act.  The Centers for Medicare and Medicaid has estimated improper Medicaid payments, in 2011, including fraud, waste and abuse, amounted to $21.9 billion.

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Page 3: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Fraud occurs when someone knowingly lies to obtain some benefit or advantage

4 factors distinguish fraud:1. A false misrepresentation= THE LIE2. The lie is intentional or knowingly made3. The lie is made to obtain a benefit not due to the claimant4. The lie is material—that is, it will make a difference in the benefits received.An example of fraud is knowingly billing for services not furnished or supplies not provided.

Fraud is punishable under the law

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Page 4: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Financial abuse occurs when someone uses Medicaid in a way that is contrary to the intended purpose of the system or law. Abuse also includes client practices that result in unnecessary cost to the Medicaid program.

This may also be punishable under the law

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Page 5: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Provider waste is the overutilization of services or other practices that directly or indirectly result in unnecessary costs to the healthcare system.

This is not usually punishable by law if there is not a criminal intent.

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Page 6: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

For the purposes of enforcement, there is a difference between unintentional mistake and fraudulent or abusive behavior. For example, submitting an erroneous claim for payment is different than submitting the same claim with actual knowledge, reckless disregard or deliberate ignorance. An honest mistake should lead to the return of funds to Medicaid, whereas a fraudulent or abusive claim may also lead to administrative, civil or criminal penalties.While some fraud schemes may involve legitimate care, some fraud schemes never involve real care, such as false storefronts pretending to operate a business.Medical Identity theft is defined as the misuse of a provider’s unique medical identifying information to obtain or bill public or private payors for fraudulent medical goods and services. This could be the use of a providers National Provider Number or NPI, Tax Identification Number, US Drug Enforcement Administration number and State medical license number.Billing for services or supplies not provided – Some health care professionals bill Medicaid for a covered service or item but do not actually provide the service or item or provide a different service or item that is not covered.Billing for unnecessary services or items - Each state determines what items and

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Page 7: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

services are authorized to be paid by Medicaid. Health care professionals are responsible for ensuring services meet the definition of medical necessity or are otherwise authorized.Upcoding – billing for services at a level of complexity that is higher than the service actually provided or documented.Unbundling - is billing separately for services or items that should be billed together at a lower overall rate. Cases of unbundling have risen in the context of laboratory providers. Unbundling inflates the cost of Medicaid services and items.Kickbacks – Rewarding sources of new business may be acceptable in some industries but not when Federal health care programs are involved. Kickbacks in health care can lead to overutilization, increased program costs, corruption of medical decision making, patient steering and unfair competition.Lack of documentation – Good documentation is important to protect the program, clients and providers. Documentation can help a provider avoid liability and keep out of fraud, waste and abuse trouble. If your records do not justify the items or services billed, you may have to pay that money back. Altering documentation to receive a higher rate or after services have been billed shall be considered fraud.Scheming with a client – In some situations providers go out and recruit clients. The provider may give them money or some other benefit to sign on with them.

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Page 8: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Medicaid clients can also participate in fraud and abuse. Common forms include eligibility fraud, card sharing, doctor shopping and drug diversion. Card sharing occurs when a client shares his or her Medicaid card with a person who is not covered so the person may receive services in the client’s name. This may compromise the integrity of the clients name and dangerous care that is contrary to their own. Health care professionals should require an additional form of identification in order to discourage card sharing.Doctor shopping involves clients visiting different providers to obtain multiple prescriptions for the same or a similar type of drug. Wyoming Medicaid has a prescription drug monitoring program called “lock in.” This locks in a client to a certain provider and/or pharmacy. Drug Diversion is a deflection of prescription drugs from medical sources into the illegal market or the use of prescription drugs for illegal or nonmedical purposes.

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Page 9: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Wyoming has statutes and laws in place to combat fraud, waste and abuse. Statute 42-4-301-306 is the Wyoming Medicaid False Claims Act. A person may be responsible for damages and civil penalties for:• Knowingly presenting a false or fraudulent claim for payment or approval• Knowingly make to be used a false record or statement material to a false or

fraudulent claim or• Is a beneficiary of an inadvertent submission of a false claim to any employee,

officer or agent who discovers the falsity of the claim and fail to disclose or repay the state within 90 days of discovery.

Statute 42-4-111 a person who provides or obtains assistance by misrepresentation by knowingly making a false statement or fails to disclose a material fact in providing medical assistance can be found guilty of a felony or a misdemeanor.

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Page 10: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Effective July of 2013, any person who fails to maintain records in accordance with Medicaid program rules as necessary to disclose fully the nature of the goods, services, items, facilities or accommodations when a claim has been submitted or paid under the Medicaid program may be found guilty of a misdemeanor or felony.

If it isn’t documented it didn’t happen.

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Page 11: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

18 U.S Code 1347 is the Health Care Fraud law – again whoever knowingly and willfully executes, or attempts to execute a scheme or to defraud any health care benefit program can be convicted, fined and face possible imprisonment.

Other federal laws include:Anti-kickbackPhysician Self-Referral (Stark Law)Social Security Act and United States Criminal code

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Page 12: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Most individual and organizations that work with Medicaid are honest – but there are some bad actors. This may include:• Doctor and health care practitioners• Suppliers of durable medical equipment• Employees of physicians, organizations or supplies• Employees of companies that manage billing• Clients of Medicaid

It is important for you to be aware of various entities that have been implicated in fraud schemes. Those who commit fraud could be looking for a new medical identity.

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Page 13: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

When fraudulent activities are found and prosecution has been completed, enforcement actions include exclusion from participation in any federal program. Wyoming Medicaid is required to alert the Office of Inspector General of any convictions of fraudulent behavior. The excluded party will be included in multiple federal and state exclusion lists that are available to State Medicaid agencies. Providers are required to check the exclusion lists to verify no employees have been excluded. If the state determines a provider has an excluded party working for them, payments may be recovered by Medicaid.

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Page 14: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Medicaid receives referrals from many different resources. Some of them include:• Medicaid Fraud Control Unit• Prosecution and Recovery Investigation Collection Efforts• State licensing boards • Other providers• Other clients

If a credible allegation of fraud is determined, Wyoming Medicaid is mandated by the federal government to refer the case to the Medicaid Fraud Control Unit or other law enforcement and payments to the provider must be suspended.

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Page 15: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

In February of 2006, The Deficit Reduction Act of 2005 was signed into law and created the Medicaid Integrity Program (MIP) under section 1936 of the Social Security Act. The MIP is the first comprehensive federal strategy to prevent and reduce provider fraud, waste and abuse in the Medicaid program. It also supports the program integrity efforts of the state Medicaid agencies.

The Wyoming Medicaid Program Integrity Unit:• Ensures compliance with applicable federal and state statutes, rules, regulations,

manuals, program enforcement and policy.• Identifies fraud, waste and abuse• Monitors estate recovery and third party liability to verify Medicaid is the payer

of last resort

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Page 16: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Program Integrity has many functions. Provider Education – like this video, program integrity may educate providers in person, letters, by distance learning and webinarsPrepayment reviews – If a pattern of inappropriate behavior has been determined but does not yet rise to the level of fraud, Wyoming Medicaid may decide to put the provider on pre-payment review. This review of documentation occurs prior to submitted claims being paid.Validity of claim payments – Program Integrity monitors claim payments to determine if the claims are paying correctly or denied according to certain requirements that are not met.Post payment reviews – Medicaid claims are paid on an “honor system”. In most cases Program Integrity completes post pay desk audits. Documentation will be requested by the Program Integrity unit and reviewed for reasons such as but not limited to errors, lack of documentation and medical necessity.Complaints and referrals - Wyoming Medicaid receives referrals from many different resources. Once a complaint or referral is received a preliminary investigation is started.Federal Program Coordination – Wyoming Medicaid works with the Centers for Medicare and Medicaid coordinating federal prevention efforts.

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Page 17: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Federal as well as state guidelines require providers to furnish on request financial and medical records involving services provided to Medicaid clients. Access must be provided to the Wyoming Department of Health, Centers for Medicare and Medicaid, the United States Department of Health and Human Services, all federal and state contractors, agencies or their designees. If you have decided to discontinue providing services to Medicaid clients, you are still responsible for providing access to any documents for the period services were performed.

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Page 18: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

The provider is responsible for all documentation being correct, accurate and complying with all federal and state guidelines. Documentation must be complete at the time it is billed. Documentation completed after the submission of a claim will be deemed insufficient and Medicaid funds shall be withheld or recovered. Documentation completed after submission of a claim can also be considered fraudulent.

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Page 19: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

A note must be written for every office, clinic, nursing home, hospital or others services billed to Medicaid. The record must fully disclose the extent of the services being provided.

Make sure to review all rules, regulations, manuals and policies regarding documentation. Besides Section 3.8 of the Wyoming Medicaid Provider Manual other service sections may have additional requirements. Keep up to date on any revisions to rules, policies and manuals.

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Page 20: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Retention guidelines – make sure to keep all financial and medical records for any service billed to Medicaid for a period of at least six years from the end of the state fiscal year which runs July to June. If an audit is in progress by any entity that has access to records, the records must be maintained until the audit is resolved.

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Page 21: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Additional things to remember –• Do not use white out• Do not scribble through errors – mark with a line and initial• Do not cut and paste information from one medical record to another medical

record• Limit the use of abbreviations• Include the client name, id and location of services • Month, day and year• Name of the service provided and/or the code

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Page 22: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

• When required document time service began and time service ended using standard AM & PM or military time. Be consistent.

• Signature and credentials of the person providing the service• Detailed description of the service provided

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Page 23: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

If a pattern of inappropriate billing and/or lack of documentation for services reimbursed a referral will be made to the Medicaid Fraud Control Unit, law enforcement or regulatory agencies for further investigation.

If is not documentation or written down it didn’t happen.

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Page 24: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

It all begins with good policy.• Follow all federal and state statutes, rules, regulations, policies and procedures

and make changes as a provider to meet them• Use SOAP notes or the WIDE rule• Double check all documentation to ensure it complies with all standards• Institute a quality assurance plan or committee to review monthly or quarterly

for accuracy. Complete refund of any overpayments to Medicaid within thirty (30) days

• Make sure you are meeting all HIPAA requirements• Evaluate for medical necessity or that services are covered by Medicaid

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Page 25: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

Providers play an important role in preserving the integrity of the Medicaid program, protecting clients from harm and preventing fraud, waste and abuse. By following the applicable rules, reporting suspected violations and taking preventive measures, providers may help protect their practices and at the same time make a valuable contribution to the fight against fraud, waste and abuse.

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Page 26: PI Presentation for Provider Services Workshop 5.18.15 · Physician Self-Referral (Stark Law) Social Security Act and United States Criminal code 10. Most individual and organizations

The Program Integrity Unit is always willing to assist you! You are being provided this presentation to use as a training tool for existing and new staff members. Please take the time to have them watch.

If you have any questions or concerns, please feel free to contact us at 307-777-7531 or to report any potential fraud, waste or abuse call 1-855-846-2563 or at the website provided. Thank you so much for being here today.

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