VOLUNTARY SELF-DISCLOSURE OF PROVIDER OVERPAYMENTS PACKET - in.gov of overpayment... · the...

Page 1 of 15Voluntary Self-Disclosure of Provider OverpaymentsIndiana Health Coverage Programs December 10, 2018

Eric Holcomb, GovernorState of Indiana

MS 07 402 W. WASHINGTON STREET, ROOM W374

INDIANAPOLIS, IN 46204-2739

www.IN.gov/fssa Equal Opportunity/Affirmative Action Employer

Office of Medicaid Policy and Planning

VOLUNTARY SELF-DISCLOSURE OF PROVIDER OVERPAYMENTS PACKET

Part I. Self-Disclosure Protocol

The Indiana Health Coverage Programs (IHCP), has established a self-disclosure protocol for providers wishing to report Medicaid and Children’s Health Insurance Program (CHIP) fee-for-service overpayments they have identified.

The IHCP understands that internal compliance processes often identify improper payments that have been made to a provider. While providers who determine they have received inappropriate payments from the IHCP are obligated by federal and State law to return the overpayments, the IHCP believes a process to facilitate reporting and repayment of these improper payments is beneficial to providers and the State. The self-disclosure protocol gives providers an easier process for reporting matters that involve possible fraud, waste, abuse, or inappropriate payment of funds, whether intentional or unintentional, to the IHCP. By enhancing the State’s relationship with providers through this self-disclosure approach, the IHCP hopes to further its efforts to eliminate fraud, waste and abuse, while also offering providers an opportunity to reduce their legal and financial exposure.

Providers should utilize the self-disclosure protocol to report the following self-identified items:

Provider billing system errors or issues that result in overpayments

Potential violations of federal, state, or local laws

Potential violations of regulations

Potential violations of billing, coding, or other healthcare policies

Note that the above list is not an all-inclusive list of potential errors or issues that may be reported. However, errors or overpayments that are the result of issues with the IHCP claims payment processing system should not be reported through this self-disclosure mechanism. Please report IHCP claims processing payment issues to the IHCP Provider and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Please note that the IHCP requests the self-disclosure protocol be utilized in the following scenarios:

To self-report overpayments involving specific compliance issues To self-report overpayments involving cumulative amounts greater than $1,000 To self-report overpayments involving fraud or violations of law

In the event a provider identifies a single claim, or a small number of claims, as erroneous, the IHCP recommends the provider void and (if applicable) resubmit the claim correctly through the IHCP claim-processing system.

Potential Benefits of Self-Disclosure While the resolution of each self-disclosure depends upon the merits of the specific situation, the IHCP reminds providers that self-disclosure of an overpayment will, in many circumstances, result in a better outcome for the provider than if the IHCP or other review organization discovers the matter independently.

Managed Care Overpayment Self-DisclosuresThe self-disclosure process outlined in this document is designed for providers who wish to report Medicaid and CHIP fee-for-service overpayments. Please do not report managed care overpayment issues using this process. Should you need to report managed care overpayments, please contact the specific managed care entity (MCE) involved or contact the IHCP Provider and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Self-Disclosures Involving Claim Sampling or Pharmacy Claims The self-disclosure process outlined in this document is designed for providers who wish to report claim-specific Medicaid and CHIP fee-for-service overpayments that do not include claims for pharmacy services billed on the Pharmacy Claim Form. If you would like to pursue a sampling approach or disclose overpayments related to pharmacy claims, you may use the Self-Disclosure form to request consultation with a Program Integrity representative. Include information and your request for consultation within Section 5 of the form. If you wish to discuss claim sampling or pharmacy overpayment issues with a Program Integrity representative, please do not include any dollar estimates or claims in this submission.

Provider Responsibilities

Please be advised that, under federal law, a provider who identifies an overpayment shall report the overpayment and return the entire amount to a Medicaid program within sixty (60) days after it is identified. 42 U.S.C. § 1320a-7k(d). A provider who retains an overpayment after the sixty (60) day deadline incurs an obligation under the federal False Claims Act and may be subjectto criminal and civil liability, including civil monetary penalties, treble damages and, potentially,exclusion from participation in federal health care programs. Id. A provider who fails to makethe repayment within sixty (60) calendar days of identification may also be at risk from a“whistleblower” lawsuit. The IHCP will accept repayments made within sixty (60) calendar days of your identification of an overpayment or your receipt of this notice of an overpayment.

Under the Patient Protection and Affordable Care Act (PPACA), a provider who identifies an overpayment outside of routine adjustments “shall-(A) report and return the overpayment to the Secretary, the State, an intermediary, a carrier, or a contractor, as appropriate, at the correct address; and (B) notify the Secretary, State, intermediary, carrier, or contractor to whom the overpayment was returned in writing of the reason for the overpayment.” PPACA 6402(d)(1)(A) & (B). In Indiana, one original and one copy of the completed Voluntary Self-Disclosure of Provider Overpayments Packet, including the following information shall be submitted when an overpayment is self-identified:

Completed Self-Disclosure Form (Part II)

Completed Payment Options (Section 6 of the Self-Disclosure Form) identifyingwhether the overpayment will be satisfied by a refund check or a withhold from futurepayments.

Completed Provider Corrective Action Plan (Part III)

Overpaid Claims Detail (Part IV)

Completed IHCP Request to Waive Appeal Rights (Part V)


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The address to which a provider shall submit the original version of the packet (and the repayment, if paying by check) is:

SUR Audit and OverpaymentIHCP Program Integrity

P.O. Box 636297 Cincinnati, OH 45263-6297

The address to which a provider shall submit a copy of the packet is:

MS 07Surveillance and Utilization Review Audit Manager

Office of Medicaid Policy and PlanningFamily & Social Services Administration

402 W. Washington St., Room W374Indianapolis, IN 46204

NOTE: A copy of the repayment check shall be submitted to the second address.

Failure to complete the Voluntary Self-Disclosure of Provider Overpayments Packet, including associated attachments, and to provide a refund or a plan to refund said overpayment to both of these specific addresses qualifies as failure to comply with PPACA. In addition, a provider that fails to do so may be subject to further action by the IHCP including, but not limited to, an audit of the provider’s records and/or referral for further investigation. The provider may also be liable for violations of the Federal False Claims Act.

It is each provider’s responsibility to maintain detailed records of any overpayment identified and returned in order to demonstrate compliance (regardless of refund method). Please note that if providers undertake an audit or review of their Medicare claim population, providers cannot use the Medicare error rate on their Indiana Medicaid claim population. If a provider chooses to utilize statistically valid random sampling and extrapolation to determine an overpayment amount for a large number of claims, providers should submit an explanation of the extrapolation process utilized and how the overpayments were discovered.

To avoid overpayments being included in subsequent SUR audits, providers should request claim adjustments as soon as overpayments are identified by internal audit procedures. Adjusting claims or returning overpayments following initiation of a SUR audit does not eliminate audit liability for an error that existed when the SUR team identified the claim for review and notification of an audit was sent to the provider. The net overpayment amount is included in the extrapolation process for audits completed via random sample, while the net overpayment is then deducted from the extrapolated amount.

After the IHCP reviews all disclosure submission material, you will receive a letter indicating the final overpayment dollar amount and the procedure for remitting additional payment, if necessary. If the submitted claim data does not materially match the IHCP payment data, or if the IHCP does not accept your self-disclosure results, you will receive correspondence with further instructions. Self-disclosure assumes that the provider has waived the right to administrative review and appeal. Consequently, you are asked to complete and submit the IHCP Request to Waive Appeal Rights (Part V) when you submit your self-disclosure form and data.

Page 3 of 15Voluntary Self-Disclosure of Provider Overpayments Indiana Health Coverage Programs December 10, 2018

Please note that the above list of requested information may not be all-inclusive as other information may be required, depending upon the circumstances of your self-disclosure. Files containing claims information and all self-disclosure correspondence from all sections above are to be submitted in an electronic HIPAA-compliant1 format (via encrypted CD, DVD, or other similar format) to the addresses listed above.

Should you have any questions concerning the requested information, please contact the IHCP and Member Concerns Line at (800) 457-4515, Option 8 for Audit Services.

Our Responsibilities The IHCP is required to identify and recover overpayments as mandated by federal and statelaws and regulations. Title XIX of the Social Security Act, Sections 1902 and 1903, and regulations found at 42 CFR 456, stipulate that utilization review activities of the FSSA ensure that services rendered are necessary and in the optimum quality and quantity. These federal regulations also require the IHCP to have the ability to identify and refer cases of suspectedfraud and/or abuse in the IHCP for investigation and/or prosecution. Utilization review activities safeguard against unnecessary care and services and ensure that payments are appropriate according to the coverage policies established by the IHCP (Indiana Administrative Code 405 IAC 5-1). The results and recommendations of reviews conducted for this purpose are specifically designed to assist providers in achieving compliance as well as avoiding future financial penalties incurred when payment for services is recouped.

Therefore, please be advised that self-disclosure of overpayments alone does not absolve a provider of additional liability that may be associated with claims included within a review period or claims included within a time period not examined during an internal review. Please also note that the IHCP’s acceptance of your review results and any overpayment associatedtherewith does not waive the right to further audit or to conduct an examination of these claims, or any other claims within the time period covered by your internal review process. These claims continue to be subject to review by the IHCP, the Centers for Medicare and MedicaidServices (CMS), the Office of Inspector General (OIG), other State or federal agencies or other investigative entities.

1Documentation/information shall be submitted in a Health Insurance Portability and Accountability Act (HIPAA)-compliant and secure manner. Please do not email or mail documents without using appropriate encryption methods. Passwords to encrypted files shall be e-mailed separately from the documentation or data, or provided via telephone.



Office of Medicaid Policy and PlanningMS 07

402 W. WASHINGTON STREET, ROOM W374 INDIANAPOLIS, IN 46204-2739


Part II. Self-Disclosure Form

Input the date you completed the form:

Section 1: Provider Information Complete the following fields as applicable. Alternate/Mailing Address is only required if you or your organization has a mailing address that differs from your service address.

A. Provider / Company Name

B. First Name (If Individual Provider)

C. Last Name (If Individual Provider)

D. IHCP Provider Type

E. IHCP Provider Specialties

F. IHCP Provider ID

G. Location Code (If Applicable)

H. National Provider Identifier (NPI)

I. Tax Identification Number (TIN)

J. License Number (If Applicable)

K. Street Address 1

L. Street Address 2

M. City

N. State

O. Zip Code

P. Office Telephone

Q. Fax Number

R. Alternate Telephone Number

S. Email Address (REQUIRED)

T. Alternate/Mailing Address - Street Address 1

U. Alternate/Mailing Address - Street Address 2

V. Alternate/Mailing Address - City

W. Alternate/Mailing Address - State

X. Alternate/Mailing Address - Zip Code

Please note that the submission of address changes via this process does not modify your provider enrollment information. Please visit www.in.gov/medicaid/providers for information about how you canupdate your provider enrollment information.



https://www.in.gov/medicaid/providers

Section 2: Contact Information Complete the following fields as applicable. If the information is the same as listed above, indicate "See ProviderInformation" for that line. This contact information is utilized in the event there are questions regarding the informationyou submitted in the self-report.

A. First Name

B. Last Name

C. Job Title

D. Employer

E. Division or Department

F. Relationship to Provider (Attorney, Staff, etc.)

G. Street Address 1

H. Street Address 2

I. City

J. State

K. Zip Code

L. Office Telephone

M. Fax Number

N. Alternate Telephone Number

O. Email Address (REQUIRED)

Section 3: Type of Self-Disclosed Overpayment Issue Check one or more of the options provided, below. If you select "Other," please include a brief narrative describing the issue.

A. Billing or Invoice Issue G. Facility Licensing Issue

B. Documentation / Records Issue H. Falsification / Alteration of Records / Documents

C. Quality of Care Issue I. Employee Licensing / Credentialing

D. Cost Report Issue J. Other (Provide Brief Detail, Below.)

E. Claims for Services Not Provided

F. Reporting Health Insurance

Section 4: State / Federal Agency or Law Enforcement Involvement Please complete this section if the overpayment issue(s) has (have) been referred to a state or federal agency or law enforcement OR if you were made aware of the issue(s) as a result of state or federal agency or law enforcement notification.

A. Agency Notification Occurred (Yes or No)

B. Notification Initiated by Provider (Yes or No)

C. Agency Name (e.g. CMS, MFCU, OIG, etc.)

D. Date Involvement or Notification Occurred

E. Agency Contact – First Name

F. Agency Contact – Last Name

G. Agency Contact – Title

H. Agency Contact – Telephone Number

I. Agency Contact – Email Address

Page 6 of 15Voluntary Self-Disclosure of Provider Overpayments Indiana Health Coverage Programs December 10, 2018

Section 5: Self-Disclosure Details You shall provide detailed information about your self-disclosure. DO NOT INCLUDE CLAIM NUMBERS ORMEMBER INFORMATION IN THIS SECTION.

Please be advised that under federal law, a provider who identifies an overpayment shall report the overpayment andreturn the entire amount to a Medicaid program within sixty (60) days after it is identified. 42 U.S.C. § 1320a-7k(d). A provider who retains an overpayment after the sixty (60) day deadline incurs an obligation under the federal False Claims Act and may be subject to criminal and civil liability, including civil monetary penalties, treble damages and, potentially, exclusion from participation in federal health care programs. A provider who fails to make the repayment within sixty (60) calendar days of identification may also be at risk of a “whistleblower” lawsuit.

A. Date or Timeframe Issue was Identified

B. The Dates of Service Involved

C. First and Last Names of Those Involved (If Applicable)

D. Relevant Regulatory or Medicaid Policy

E. Amount of Overpayment (Total - No Estimates)

F. Description of the Facts and Circumstances Surrounding the Errors / Inappropriate Payment (Attach Letterwith Details and Indicate ‘See Attached Letter’ in This Section if Additional Space is Necessary):


Section 6: Payment Options Complete the following fields as applicable.

A. I Have Attached a Check Payable to The State of Indiana (Yes or No)

B. I Have NOT Attached A Check. Please Withhold the Overpayment Amount Identified Abovefrom Future Medicaid / CHIP Payments (Yes or No)

Section 7: Certification Statement Self-disclosure offers providers the opportunity to minimize the potential cost and disruption of a full-scale audit and investigation. The IHCP's acceptance of self-disclosure review results and any overpayment associated therewith doesnot waive the right to further audit or to examine these claims, or any other claims within the time frame covered by your internal review process. Any claims identified as part of this self-disclosure process continue to be subject to review by the IHCP, the Centers for Medicare and Medicaid Services (CMS), the Office of Inspector General (OIG),other State or federal agencies, or other investigative entities. Self-disclosure will not absolve the provider of criminal or civil culpability. If a law enforcement agency determines that a crime was committed, any information shared with the IHCP will be forwarded to the appropriate agency.

I certify that, to the best of my knowledge, the information in this self-disclosure is truthful and is based on a good faith effort to assist the Indiana Health Coverage Programs in its inquiry and verification of this disclosed matter.

A. Printed First and Last Name

B. Signature

C. Job Title

D. Date






Part III. Provider Corrective Action Plan

Contact Information Complete the following fields as applicable. This contact information is utilized in the event there are questions regarding the information you self-report.

A. Provider Name

B. Contact Person First and Last Name

C. IHCP Provider ID

D. Street Address 1

E. Street Address 2

F. City

G. State

H. Zip Code

I. Office Telephone

J. Fax Number

K. Email Address (REQUIRED)

L. Date Form Completed

Corrective Action Detail Describe planned corrective action and/or corrective action that has already occurred (attach document with same format as below and indicate ‘See Attached Corrective Action Plan’ in this section if additional space is necessary). Corrective action SHALL INCLUDE each action to be taken or already taken, the responsible party for each action, and thedate each action has been or will be completed.

Number Issue Description Corrective Action Responsible Party Date Completed

or Expected



Corrective Action Detail Describe planned corrective action and/or corrective action that has already occurred (attach document with same format as below and indicate ‘See Attached Corrective Action Plan’ in this section if additional space is necessary). Corrective action SHALL INCLUDE each action to be taken or already taken, the responsible party for each action, and thedate each action has been or will be completed.

Number Issue Description Corrective Action Responsible Party Date Completed

or Expected






Part IV. Overpaid Claims Detail – Possible Format

Contact Information Complete the following fields as applicable. This contact information is utilized in the event there are questions regarding the information you self-report.

A. Provider Name

B. Contact Person First and Last Name

C. IHCP Provider ID

D. Street Address 1

E. Street Address 2

F. City

G. State

H. Zip Code

I. Office Telephone

J. Fax Number

K. Email Address (REQUIRED)

L. Date Form Completed

Overpaid Claims Detail Part IV of this Form may be utilized or duplicated in Microsoft Excel if additional rows are necessary . In addition, you may need to include additional columns dependent upon the claim form you use, your provider type, and your specialty.

Row Claim ID

Number (ICN)Member ID Member Name

Billing Provider ID

Rendering Provider ID

Billed Amount

Claim Paid Amount

Refund Amount

Refund Reason



Row Claim ID

Number (ICN) Member ID Member NameBilling

Provider ID Rendering Provider ID

Billed Amount

Claim Paid Amount

Refund Amount

Refund Reason



Row Claim ID

Number (ICN) Member ID Member NameBilling

Provider ID Rendering Provider ID

Billed Amount

Claim Paid Amount

Refund Amount

Refund Reason



Row Claim ID

Number (ICN) Memeber ID Member NameBilling

Provider ID

Rendering

Provider ID

Billed Amount

Claim Paid Amount

Refund Amount

Refund Reason






Part V. Indiana Health Coverage Programs (IHCP)

Request to Waive Appeal Rights (For This Case Only)

Please complete the contact information (including signature) at the bottom of the page should you wish to request to forego the Administrative Reconsideration process outlined in Indiana Code (IC) 12-15-13-3.5.

I/we believe that an overpayment has occurred. I/we confirm that I/we will repay the overpayment amount, including interest pursuant to 405 IAC 1-1-5. I/we understand that, pursuant to IC 12-15-13-3.5(c), by requesting to forego the administrativereconsideration process, I/we waive the right to appeal this case. My signature on this page confirms my/our understanding of IC 12-15-13-3.5 and affirms my/our request to waive my/our right to appeal this case.

Please be advised that under federal law, a provider who receives an overpayment shall report the overpayment and return itwithin 60 days after it is identified, 42 U.S.C. § 1320a-7k(d). A provider who retains an overpayment after the sixty (60) day deadline incurs an obligation under the federal False Claims Act and could be subject to criminal and civil liability, including civil monetary penalties, treble damages and, potentially, exclusion from participation in federal health care programs. Id. A provider who fails to make the repayment within sixty (60) calendar days of identification may also be at risk from a “whistleblower” lawsuit. The FSSA will accept repayments made within sixty (60) calendar days of your receipt of this notice. Failure to make the repayment within three hundred (300) calendar days will result in recoupment of the amount due against current claims. For questions, please contact 1-800-457-4515 or (317) 234-7598.

Complete the following information.

Provider Business Name:

Provider Name:

Title:

IHCP Provider ID and/or NPI:

Telephone Number:

Email Address (Optional):

Provider Signature:

Date:

An original and a copy of the form shall be sent in accordance with the submission guidelines in Part I, above.



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