Annual Fraud, Waste, & Abuse Training for Providers

Annual Fraud, Waste, & Abuse Training for

Providers

Melissa S. BerdellDirector, National Program Integrity

Value Behavioral Health of PA(formerly Melissa S. Hooks)

Overview of PresentationOverview of Presentation

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Definitions & Types – Fraud, Waste, & Abuse Background & Regulations for Program Integrity Program Integrity Activities Provider Responsibilities Overview of Documentation Requirements New Program Integrity Information & Topics

Definitions & Types:Fraud, Waste, & Abuse

Program Integrity DefinitionsProgram Integrity Definitions

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FRAUD• Any intentional deception or misrepresentation made by an

entity or person in a capitated MCO, Primary Care Case Management, or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting.


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ABUSE• Any practices in a capitated MCO, Primary Care Case

Management program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice & which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, & requirements of state or federal regulations) for health care in the managed care setting.


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WASTE• Thoughtless or careless expenditure, consumption,

mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls.

Other Program Integrity DefinitionsOther Program Integrity Definitions

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Compliance Program• Systematic procedures instituted to ensure that contractual &

regulatory requirements are being met

Compliance Risk Assessment• Process of assessing a company’s risk related to its compliance

with contractual & regulatory requirements

Other Program Integrity DefinitionsOther Program Integrity Definitions

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Compliance Work Plan• Prioritization of activities & resources based on the Compliance

Risk Assessment findings

Program Integrity• Steps & activities included in the compliance program & plan

specific to fraud, waste & abuse

Types of FraudTypes of Fraud

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Falsifying Claims/Encounters• Billing for services not rendered• Billing for services provided by unlicensed or unqualified

persons• Misrepresentation of the service/supplies rendered (not

accurately documenting or omitting details of the actual services provided, billing for more time or units of service than provided, upcoding)

• Altering claims• Submission of any false data on claims, such as date of

service, provider or prescriber of service• Duplicate billing for the same service


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Administrative/Financial • Falsifying credentials• Fraudulent enrollment practices• Fraudulent third-party liability reporting• Offering free services in exchange for a recipient's Medical

Assistance identification number• Providing unnecessary services/overutilization• Kickbacks-accepting or making payments for referrals• Concealing ownership of related companies


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Abuse of Recipients• Physical, mental, emotional or sexual abuse• Discrimination• Neglect• Providing substandard or inappropriate care


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Denial of Medically Necessary Services• Denying access to services• Limiting access to services• Failure to refer to needed specialist• Underutilization


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Overutilization of Services• Providing unnecessary services• Unbundling multiple services• Overlapping services• Billing for excessive units• Documentation does not support the time billed


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Recipient FWA• Forging or altering prescriptions or orders• Using multiple ID cards• Loaning his/her ID card• Reselling items received through the Medical Assistance

program• Intentionally receiving excessive drugs, services or supplies

Background & Requirements for Program Integrity

Federal RegulationsFederal Regulations

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Federal False Claims Act (FCA)• FCA is federal statute that covers fraud involving any federally funded

contract or program, including the Medicare (as well as Medicare Advantage & Medicaid programs.

• Any individual or organization that knowingly submits a claim he or she knows (or should know) is false & knowingly makes or uses, or causes to be made or used, a false record or statement to have a false claim paid or approved under any federally funded health care program is subject to civil penalties.

• Potential penalties: Triple damages & penalties between $5,500 & $11,000 for each false claim Exclusion from participating in federally funded programs including

Medicare & Medicaid Criminal prosecution


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Balanced Budget Act (BBA)• Amended Social Security Act (SSA) to include healthcare crimes• Must exclude from Medicare & state healthcare programs for those

individuals & entities convicted of healthcare offenses• Can impose civil monetary penalties for anyone who arranges or

contracts with excluded parties


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Anti-Kickback Statute• A federal law (42 U.S.C. §§ 1320a-7b) that prohibits persons from

directly or indirectly offering, providing or receiving kickbacks or bribes in exchange for goods or services covered by Medicare, Medicaid & other federally funded health care programs. These laws prohibit someone from knowingly or willfully offering, paying, seeking or receiving anything of value in return for referring an individual to a provider to receive services, or for recommending purchase of supplies or services that are reimbursable under a government health care program. Violations of the law are punishable by the following:

• Criminal sanctions including imprisonment & civil monetary penalties. • The individual or entity may also be excluded from participating with

other federally funded programs, including Medicare &Medicaid.


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Fraud Enforcement & Recovery Act of 2009 (FERA)• A federal law that increased detection & law enforcement of crimes

related to fraud.• FERA amended the FCA definition of fraud.• FERA infused millions of dollars into law enforcement initiatives to

combat fraud in the Medicare & Medicaid programs.• FERA included whistle-blower protections.


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Patient Protection & Affordable Care Act (PPACA –Healthcare Reform Act)

• A federal law for increased access to healthcare that included provisions specific to fraud & abuse. PPACA increased penalties & enforcement of healthcare crimes.

• PPACA mandates state & federal agencies to communicate about provider enrollment for federally funded programs.

• PPACA required Medicare & Medicaid providers to have a compliance program.

• PPACA reduced the requirements of “intent.”• PPACA stated that overpayments must be reported & returned within

60 days.

State RegulationsState Regulations

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Pennsylvania Code• Chapter 55 Part III. Medical Assistance Manual

http://www.pacode.com/secure/data/055/partIIItoc.html

• General Regulations http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html

• Payment Regulations http://www.pacode.com/secure/data/055/chapter1150/chap1150toc.html

• Medical Assistance Bulletins http://www.dhs.pa.gov/


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Pennsylvania - PA PROMISe • PA PROMISe Provider Handbooks

www.dhs.pa.gov

• PA Recovery (for information by level of care) http://www.parecovery.org/


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Pennsylvania HealthChoices • HealthChoices Behavioral Health Publications

http://www.dhs.state.pa.us/cs/groups/webcontent/documents/manual/p_003130.pdf

VBH-PA Provider Manual RequirementsVBH-PA Provider Manual Requirements

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VBH-PA Provider Manual• http://www.vbh-pa.com/provider/info/prvmanual/toc.htm

FWA Webpage• http://www.vbh-

pa.com/provider/info/prvmanual/6_ClmsPyt/fraud_abuse.htm

Program Integrity Activities

FWA Trends in Behavioral Health that Result in AuditsFWA Trends in Behavioral Health that Result in Audits

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Billing for services not rendered • Community & home based services are vulnerable

Misrepresenting of falsifying documentation • Service does not meet the requirements for the service code

Forgery of recipient signatures• Treatment plans & encounter forms

Falsifying or misrepresenting credentials• Credentials do not meet minimum requirements

Over-prescribing or unnecessary prescriptions• Misuses with Suboxone & Methadone

Federal Audits & InspectionsFederal Audits & Inspections

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Medicaid Integrity Program (MIP) Medicaid Integrity Group (MIG) Medicaid Integrity Contractors (MIC) Medicare Zone Integrity Contractors (ZPIC) Medicare Recovery Audit Contractors (RAC)

http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol4/xml/CFR-2011-title42-vol4-sec455-23.xml

Federal Audits & InspectionsFederal Audits & Inspections

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New York: Regions 1,2

Pennsylvania Collaboration Pennsylvania Collaboration

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“All together, as providers, BH-MCOs, OMHSAS, & BPI, we can help to reduce FWA to decrease wasteful spending in our system.”

Other Enforcement EntitiesOther Enforcement Entities

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U.S. Department of Health & Human Services, Office of Inspector General (OIG)

U.S. Department of Justice (DOJ) Office of the State Attorney General (AG) –

Medicaid Fraud Control Unit (MFCU) Federal Bureau of Investigation (FBI) Department of Insurance (DOI)

VBH-PA Program Integrity AuditsVBH-PA Program Integrity Audits

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Routine Audits• Scheduled or standard data validation audits, & claims

sampling, of contracted providers to ensure compliance with documentation, laws, regulations & billing requirements. The purpose of these audits will also be to monitor providers for possible fraud & abuse. Control assessments, compliance programs, & policies & procedures will be monitored & analyzed for inconsistencies, risk, etc.

• Audit procedures will be followed for routine audits http://www.vbh-pa.com/fraud/pdfs/Audit_Process.pdf


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Audit Procedures• Audit Procedures• Audit notification • Pre-audit conference call with provider• Entrance meeting with provider for on-site reviews (1st day of

audit)• Preliminary exit meeting with provider for on-site reviews (last

day of audit)• Exit conference call with provider• Report to provider• Provider audit response (CAP or reconsideration)


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Investigations or allegations of potential fraud & abuse that may involve other oversight entities are NOT routine audits & can deviate from the audit procedures.

Provider Responsibilities with Compliance

Federal Regulations - Provider ResponsibilitiesFederal Regulations - Provider Responsibilities

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Compliance Program1. Written policies & procedures2. Compliance Officer & Compliance Committee3. Effective training & education4. Effective lines of communication between the Compliance

Officer, Board, Executive Management & staff (incl. an anonymous reporting function)

5. Internal monitoring & auditing6. Disciplinary enforcement7. Mechanisms for responding to detected problems

8. Compliance Programs Must be Effective

Pennsylvania Regulations - Provider ResponsibilitiesPennsylvania Regulations - Provider Responsibilities

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Provider Responsibilities 1101• http://www.pacode.com/secure/data/055/chapter1101/s1101.51.html

Medically Necessary Services 1101• http://www.pacode.com/secure/data/055/chapter1101/s1101.21a.html

Provider Prohibited Acts 1101• http://www.pacode.com/secure/data/055/chapter1101/s1101.75.html


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Self-Audit & Disclosure Protocol• DHS outlined specific procedures to follow on the following

webpage: http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/medicalassistan

ceproviderselfauditprotocol/

• DHS requires providers to return overpayments within 60 days of identifying overpayments

• For PA HC PSR, providers should conduct self-audits & return overpayments to BH-MCO (VBH-PA) http://www.vbh-

pa.com/fraud/pdfs/Provider_Self_Audit_Referral_Form.pdf

• Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered


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Medically Necessary Services• § 1101.21a. Clarification regarding the definition of

‘‘medically necessary’’—statement of policy.

A service, item, procedure or level of care that is necessary for the proper treatment or management of an illness, injury or disability is one that: (1) Will, or is reasonably expected to, prevent the onset of an illness, condition, injury or disability. (2) Will, or is reasonably expected to, reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury or disability. (3) Will assist the recipient to achieve or maintain maximum functional capacity in performing daily activities, taking into account both the functional capacity of the recipient & those functional capacities that are appropriate of recipients of the same age.


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Minimum Documentation Requirements• Chapter 1101.51 (e), states that:

Providers shall keep records that “fully disclose the nature & extent of the services rendered to MA recipients, & that meet the criteria established in this section & additional requirements established in the provider regulations.”

Documentation Requirements

Importance of DocumentationImportance of Documentation

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Documentation – Just as Important as the Service:• The ability of the physician & other healthcare professionals to

evaluate & plan the patient’s immediate treatment, & to monitor his/her healthcare over time

• Communication & continuity of care among the physicians & other healthcare professionals involved in the patient care

• Accurate & timely claims review & payment• Appropriate utilization review & quality of care evaluations• Collection of data that may be used for research & education• Evidence that the services were provided

Consent To Treatment

Consent FormsConsent Forms

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Main Purpose of Consent Forms1. Obtain consent to diagnosis or treat2. Obtain consent to release health information for

payment & continuity of care

PA Regulations for Consent FormsPA Regulations for Consent Forms

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Pennsylvania Code • Chapter 1101 General Provisions

http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html § 1101.75. Provider prohibited acts.

a) An enrolled provider may not, either directly or indirectly, do any of the following acts:

10) Except in emergency situations, dispense, render or provide a service or item without a practitioner’s written order & the consent of the recipient or submit a claim for a service or item which was dispensed or provided without the consent of the recipient.

PA Regulations for Consent FormsPA Regulations for Consent Forms

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Pennsylvania Code• Chapter 5200 Psychiatric Outpatient Clinics

http://www.pacode.com/secure/data/055/chapter5200/chap5200toc.html § 5200.41. Records.

a) Under section 602 of the Mental Health & Mental Retardation Act of 1966 (50 P. S. § 4602), & in accordance with recognized & acceptable principles of patient record keeping, the facility shall maintain a record for each person admitted to a psychiatric clinic. The record shall include the following:

4) Appropriately signed consent forms.

VBH-PA Requirements for Consent FormsVBH-PA Requirements for Consent Forms

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VBH-PA Provider Manual • Treatment Records

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_standards.htm

Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

• 8) Each record includes the patient’s address, employer or school, home & work telephone numbers, emergency contacts, marital/legal status, appropriate consent forms & guardianship information, if relevant;

• 26) Informed consent for medication & the patient’s understanding of the treatment plan are documented;

Minimum Documentation for Consent FormsMinimum Documentation for Consent Forms

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Minimum Documentation Standards:• Name and signature of the member, or if appropriate, legal

representative• Name of the provider (should correspond with license)• Type of services and/or treatment• Benefits and any potential risks• Alternative services and/or treatment• Date and time consent is obtained• Statement that treatment and services were explained to patient or

guardian• Signature of person witnessing the consent (clinician)• Name and signature of person who explained the procedure to the

patient or guardian

Consent to Treatment FindingsConsent to Treatment Findings

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Common Findings:• No consent to treatment in member record• Consent to treatment was not signed• Consent to treatment was signed after the treatment plan• Consent to treatment was signed after services were provided

Release of Information

Release of InformationRelease of Information

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Main Purpose of Release Information1. Treatment & authorization2. Coordination of care3. Payment & audit purposes

VBH-PA Requirements for Release of InformationVBH-PA Requirements for Release of Information

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VBH-PA Provider Manual • Treatment Record Reviews

http://www.vbh-pa.com/provider/info/prvmanual/4_PartPrvResp/tx_record_reviews.htm

VBH-PA will gain access to treatment records by reviewing them at the provider’s office or by asking the provider to photocopy & send the records. Prior to treating a member, the provider should obtain the member’s written consent to share their treatment information & records with VBH-PA.

Minimum Documentation for Release of InformationMinimum Documentation for Release of Information

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Minimum Documentation Requirements• Member’s name or Medical Assistance identification number• Date of release• Expiration of release• Dates of service range for the release• Statement that the complete member record including treatment

information in progress notes & evaluations will be released for audit, quality, & payment purposes

• Signature of Member or Guardian & signature date• Clinician’s signature, credentials, & signature date

Release of Information FindingsRelease of Information Findings

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Common Findings• No release of information in member record• Release of information was not signed• Release of information was signed after the treatment plan• Release of information was signed after services were

provided

Treatment Plan

Treatment (Service) PlansTreatment (Service) Plans

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Main Purpose of Treatment (Service) Plans1. Definition of Treatment

Goals & Objectives Utilization

2. Description of Informed Consent As recorded on the Consent Form

3. Mechanism to Track Individual Plans, Treatments, & Outcomes throughout Treatment

PA Regulations for Treatment PlansPA Regulations for Treatment Plans

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http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html 1101.51. Ongoing responsibilities of providers.

(1) General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services & suppliers of medical goods & equipment shall keep patient records that meet all of the following standards:

(v) Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities & dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.

VBH-PA Requirements for Treatment PlansVBH-PA Requirements for Treatment Plans

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3. Accurately document at least the following on each case for which services are being provided:

a. Member information (demographic);b. Clinical information;c. Clinical assessments;d. Treatment plans;e. Services provided;f. Contacts with member’s family, guardians or significant others;g. Treatment outcomes; andh. PCPC/ASAM for substance abusers;


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5. All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment & disposition/discharge plan. Medical & psychological treatment documentation & progress notes must be current & treatment plans shall be updated as necessary for the level of care.

6. It is necessary that the provider initiating treatment document an initial treatment plan that describes the active target interventions with specific, measurable goals, & stated in behavioral terms, at the level of care proposed;


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24. Treatment plans are consistent with diagnoses & have objective, measurable goals & estimated time lines for achieving goals or resolving problems;

25. The focus of treatment interventions is consistent with the treatment plan goals & objectives;

26. Informed consent for medication & the patient’s understanding of the treatment plan are documented;

27. Progress notes describe the patient’s strengths & limitations in achieving treatment plan goals & objectives;


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Minimum Documentation Requirements1. Must be completed according to service requirements2. Treatment plan date3. Diagnoses and/or symptoms addressed4. Clinician’s signature, credentials, & signature date5. Member or guardian’s signature & signature date6. Evidence member or guardian participated with treatment plan development7. Goals & objectives based on evaluation & mental health strengths & needs


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Minimum Documentation Requirements8. Treatment objectives & prescribe as an integrated program of therapies, activities, experiences, & appropriate education designed to meet these objectives9. Treatment goals are measurable10. Treatment goals have established timeframes11. Treatment plan address notes less restrictive alternatives that were considered12. Treatment plan is easy to read & understand13. Treatment plan documents necessity for services14. Treatment plan documents the utilization of services

Treatment Plans FindingsTreatment Plans Findings

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Common Findings • Clinical Documentation Exceptions & Findings:

No valid treatment plan for date of service Incomplete treatment plan for date of service

• Missing member/parent signatures• Does not include frequency of services, such length of service &

session per week or month• Does not include diagnosis and/or symptoms & behaviors• Does not describe consent to treatment and/or member/parent

involvement • Treatment goals & objectives are not measurable • Treatment goals & objectives do have timeframes• Treatment plan does not reference information from evaluation

Progress Note

Progress NotesProgress Notes

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Main Purpose of Progress Notes1. Document progress at each visit, change in diagnosis,

change in treatment & response to treatment2. Document medical necessity & justification for

payment from Medical Assistance

PA Regulations for Progress NotesPA Regulations for Progress Notes

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http://www.pacode.com/secure/data/055/chapter1101/chap1101toc.html §1101.51. Ongoing responsibilities of providers.

1. General standards for medical records. A provider, with the exception of pharmacies, laboratories, ambulance services & suppliers of medical goods & equipment shall keep patient records that meet all of the following standards:

i. The record shall be legible throughout. ii. The record shall identify the patient on each page. iii. Entries shall be signed & dated by the responsible licensed

provider. Care rendered by ancillary personnel shall be countersigned by the responsible licensed provider. Alterations of the record shall be signed & dated.


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iv. The record shall contain a preliminary working diagnosis as well as a final diagnosis & the elements of a history & physical examination upon which the diagnosis is based.

v. Treatments as well as the treatment plan shall be entered in the record. Drugs prescribed as part of the treatment, including the quantities & dosages shall be entered in the record. If a prescription is telephoned to a pharmacist, the prescriber’s record shall have a notation to this effect.

vi. The record shall indicate the progress at each visit, change in diagnosis, change in treatment & response to treatment.

vii. The record shall contain summaries of hospitalizations & reports of operative procedures & excised tissues.


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viii. The record shall contain the results, including interpretations of diagnostic tests & reports of consultations.

ix. The disposition of the case shall be entered in the record. x. The record shall contain documentation of the medical

necessity of a rendered, ordered or prescribed service.

VBH-PA Requirements for Progress NotesVBH-PA Requirements for Progress Notes

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Participating providers are expected to maintain clinical record keeping systems that meet the following basic requirements:

5) All members’ treatment records must contain a bio-psychosocial assessment; treatment plan, follow-up assessments, focus of treatment & disposition/discharge plan. Medical & psychological treatment documentation & progress notes must be current & treatment plans shall be updated as necessary for the level of care.

Minimum Documentation for Progress NotesMinimum Documentation for Progress Notes

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Minimum Documentation Standards1. Must be completed for each billable encounter2. Name or Medical Assistance identification number3. Date of service4. Start & stop times of service5. Units match the claims billing6. Place of service (specific location for community services)

Minimum Documentation for Progress NotesMinimum Documentation for Progress Notes

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Minimum Documentation Standards7. Reason for the session or encounter8. Treatment goals addressed9. Current symptoms & behaviors10. Interventions & response to treatment11. Next steps & progress in treatment12. Narrative with the clinical justification to support utilization &

time billed13. Supporting documentation, when applicable14. Clinician’s signature, credentials, & signature date

Progress Notes FindingsProgress Notes Findings

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Progress notes do no support medical necessity or the time billed:

Pennsylvania Code & regulations specifically state that providers must Fully disclose & describe the services that are billed under Medical Assistance:

• The record shall indicate the progress at each visit, change in diagnosis, change in treatment & response to treatment

• The progress note must specific services rendered• The progress note must support medical necessity & justify the time

billed The treatment plan should define the utilization & support the

medical necessity for the frequency & length of service Then the progress note should fully disclose the service

provided


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Non-billable service documented in progress notes:

Case management, central intake or records, training, administration, social rehabilitation, program evaluation or research

Travel & transportation Cancelled appointments Clinic service provided over the telephone

• Please note that documenting non-billable services is still necessary but can not be submitted for payment


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Common Audit Findings:• No progress note• No services were rendered (no shows)• No narrative• Progress note is illegible• Inaccurate units billed• Progress note does not provide specific location• Progress note does not have start & stop times


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Common Audit Findings:• Rounding units

Exception case management & resource coordination

• Services were unbundled & billed individually This applies when services are paid by events or per diems Examples: crisis diversion & methadone maintenance

• Services are bundled This applies when services are paid by units of time Examples: BHRS or case management


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Common Audit Findings:• Correction to note is not initialed and/or dated

In 2015, this could result in identified overpayment

• Progress note details (service code, units, time) do not match encounter form or claim

• Incorrect service code or modifier billed• Progress note is not signed and/or dated by clinician


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Common Audit Findings: Progress note does not state reason for the encounter Progress note does not state treatment plan goals & objectives Progress note does not reference symptoms or behaviors Progress note does not have next steps in treatment Progress note does not state intervention Progress note or narrative is a duplication or almost a duplication

of previous note or narrative Supporting documentation was not attached, when required

• Example: BHRS

Encounter Form

Encounter FormsEncounter Forms

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Encounter Form1. Verify services were provided

Encounter form must be signed after the session

2. Meet the Federal regulations for Medicaid programs 42 CFR – Public Health www.gpo.gov

• 455.20 Recipient verification procedurea) The agency must have a method for verifying with

recipients whether services billed by providers were received

PA Regulations for Encounter FormsPA Regulations for Encounter Forms

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Pennsylvania Bulletins• PA Medical Assistance Bulletin #99-89-05

The Department’s policy has always been that medical assistance invoices must have either the recipient’s signature or the words “signature exception” appearing in the signature field. The signature certifies that the recipient received a medical service or item that the recipient listed on the Medical Service Eligibility Card is the individual who received the service.

PA Regulations for Encounter FormsPA Regulations for Encounter Forms

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Pennsylvania Bulletins• PA Medicaid Bulletin# 99-03-021, Health Insurance

Portability & Accountability Act (HIPAA) Transaction & Code Sets Updates, December 2003 Providers who bill via continuous-print claim forms (pin fed)

or electronic media must retain the recipient’s signature on file using the Encounter Form. The purpose of the recipient’s signature is to certify that the recipient received the service from the provider indicated on the claim form, & that the recipient listed on the Pennsylvania ACCESS Card is the individual who received the service.

VBH-PA Requirements for Encounter FormsVBH-PA Requirements for Encounter Forms

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Minimum Documentation Standards1. Must be completed for each billable encounter (except for

services that are excluded from encounter form requirements)2. Member name including member identification number (as

required in the PA Medicaid Bulletin)3. Type of service4. Date with start & stop times5. Total units billed6. Signature of Member for each encounter7. Clinician’s signature, credentials, & signature date

Encounter Form FindingsEncounter Form Findings

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Common Audit Findings:• No encounter form• Encounter form is not signed by member, parent, guardian, or

agent• Encounter form does not include start & stop times• Encounter form does not include type of service• Encounter form not signed by clinician• Correction to encounter form is not initialed and/or dated• Encounter form details (service code, units, time) do not match

progress note or claim

New Program Integrity Information & Topics

New FWA Section in Provider ManualNew FWA Section in Provider Manual

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VBH-PA Provider Manual Update• Fraud & Abuse, Claims Payment Section 6:

http://www.vbh-pa.com/provider/info/prvmanual/6_ClmsPyt/fraud_abuse.htm

New Minimum Documentation RequirementsNew Minimum Documentation Requirements

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VBH-PA Fraud & Abuse Webpage• Treatment & Psychotherapy Services http://www.vbh-pa.com/fraud/pdfs/Treatment-

Psychotherapy-Services.pdf

• Therapeutic & Rehabilitation Services http://www.vbh-pa.com/fraud/pdfs/Therapeutic-

Rehabilitation-Services.pdf

Updates to FWA PolicyUpdates to FWA Policy

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VBH-PA Program Integrity Policy Updates• Credible allegations of fraud• Pre-payment reviews as part of Corrective

Action Plan• Provider Self-Audit Protocol

Questions?Melissa S. Berdell, DHCE(c), MS, AHFI, CFE

(formerly Melissa S. Hooks)

Director, National Program IntegrityValue Behavioral Health of Pennsylvania

[email protected](724)744-6513

http://www.vbh-pa.com/fraud_abuse.htm

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Annual Fraud, Waste, & Abuse Training for Providers

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