Medicaid Educational ConferenceDecember 7, 2016

Elizabeth Smith

Medicaid Inspector General

Mission of OMIG:

To detect and prevent fraud, waste, and abuse within the medical assistance program.

OMIG’s Requirements

Verify whether services reimbursed by Medicaid were properly billed and actually furnished to beneficiaries;

Recover improperly expended funds;

Report fraud and abuse to US HHS;

Refer cases to AG MFCU & law enforcement for criminal prosecution;

Recommend and implement changes to the Medicaid program.

Prevent waste in the program

Identify policies needing revision• Unclear

• Too broad

• No longer necessary

• Too restrictive

• Negative impact on outcome

Implement changes to Medicaid programs

ABC’s of Medicaid Auditors• OMIG - Office of Medicaid Inspector General• MIC - Medicaid Integrity Contractor (Health

Integrity)• ZPIC/UPIC – CMS Program Integrity Contractors • SURS - Medicaid Utilization and Review audits• QIO - Quality Improvement Organizations• Ark. Legislative Audit – auditing Ark. Medicaid

Program by review of provider billing

OMIG Data AnalyticsFraud Detection System – billing claims

• Provider Spike Detection

• Peer Review Analysis and Outlier Identification

• Algorithms

• Claims Risk Analysis

Top outliers are selected for audit– When billing stands out from the average in a peer

group

Or send Provider Awareness Letter – request provider review billing practices in lieu of audit

Data Analysis Report– Individual provider’s values for reviewed behavior patterns– Peer group averages for reviewed behavior patterns– Claims detail for all claims included in behavior pattern

calculation

if billing is determined to be improper – corrective action plan

AUDIT PROCESSESField Audit

• On-site Review• Conduct Staff and Management Interviews• Audit Scope

• OMIG may review claims that are 3 years old• OMIG may review claims that are 5 years old if

fraud is suspected

AUDIT PROCESSES

Desk Audit• Off-site Review• OMIG requests records from the provider• The provider must respond to a records request within

14 calendar days• Audit Scope

• Identical to field audits

RECORDS REQUESTAuthority as Program Integrity Function

• Arkansas Medicaid Manual • §142.300 - Conditions Related to Record Keeping• Enrollment Contract requirement • §151.000 - Grounds for Sanctioning Providers

Subpoena Power and Production of Records• Ark. Code Ann. §20-77-2506

• Records may be requested from providers when they are not being audited

• Subpoena employment records

• Subpoena records to determine overlapping services

• Records request for Medicaid providers utilizing hospital facilities

AUDIT RESULTSWill be provided in Audit Report Letter• Findings

• Recovery or Recoupment/Corrective Action Plans*• Area of Concern• Observations • No findings• MFCU/Law Enforcement Referral

• Credible allegation of fraud-requires temporary suspension; possible suspension of performer only

Corrective Action Plans

• Based on OMIG Audit Report

• Develop plan of action addressing findings,observations, and areas of concern

• Be specific in your steps and procedure

• Provide a person/name/position for accountability

• OMIG.ARKANSAS.GOV

Corrective Action Plans

Website

steps

Self-Reporting & Self-Disclosure• Protocols for efficient self-disclosure

• Provider’s good faith -a mitigating factor

• Self-Disclosure Protocol on OMIG website

• OMIG.Arkansas.gov

• Reversing claims-Creates uncertaintyregarding questioned claims

OMIG FY 2016 REPORTField Audits 78 Desk Audits 237Recoupment Letters 1033 MIC Reviews 2Provider Awareness Letters 42 False Claims Act Rev. 124

total: 1516Provider Self-Reports 18

Recoupments & Recoveries $2.7 Million

Provider Fraud Referrals 51 (33 NPIs) 11 arrests and 13 suspensions of enrolled performing providers

Beneficiary Fraud Referrals 38

Crossover ClaimsSchool District Matching FundsEmergency TransportationPhysician & Advanced Practice Nurse BillingHospital One-Day Stay Reviews90853 Group PsychotherapyProvider Awareness LettersHHS/OIG Herceptin Claims

Continued Crossover ClaimsSchool Based Therapy reviewsPersonal Care Assistants and Home Health Service Worker Registration ProjectPeer Group Studies and Batch ReviewsRecommendations for Reform and Provider Manual Changes

Elizabeth Smith

Medicaid Inspector General323 Center Street, Ste. 1200

Little Rock, AR 72201

501-682-8349

Elizabeth.smith@omig.arkansas.gov