12.2M 78.3M Medical Offices: 690 · • Extensive and diverse experience in the investigation of...
Transcript of 12.2M 78.3M Medical Offices: 690 · • Extensive and diverse experience in the investigation of...
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Building an SIU that is nimble and audit ready
HCCA Managed Care Compliance ConferenceJanuary 27 – 30, 2019 | Lake Buena Vista, FL
Marita Janiga, Executive Director, Ethics & Compliance Investigations
Tamara Neiman, Director, Ethics & Compliance Investigations, National Special Investigations Unit
Mark Horowitz, Sr. Manager, Enterprise Regional Ethics & Compliance, Care Delivery & Pharmacy
1 | Copyright © 2019 Kaiser Foundation Health Plan, Inc.
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Kaiser Permanente Facts
8including D.C.
Regions
Nurses: 58,345Physicians: 22,013
Nurses and Physicians
217,173
Employees
Hospitals: 39Medical Offices: 690
Hospitals & Medical Offices
78.3M
Annual Prescriptions Filled
12.2M
Members
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Ethics & Compliance Investigations
Compliance Investigations
Case Management &
Reporting Unit
National Special
Investigations Unit
National
Fraud Control
Unit
Strategy &
Program Manage
ment
HOTLINE
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Ethics & Compliance Investigations
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2017 Report Volumes
Hotline (3rd party vendor)
Reported directly to Compliance
5284 cases 7070 cases
2.5 Hotline calls per employee
(Navex Global Inc. industry benchmark: 1.4 per 100 employees)
2.6 DE cases per employee
Anonymous: 60% Anonymous: 4%
Non-Anonymous: 40% Non-Anonymous: 96%
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Integrate Systemness
Triage every case using our
national assignment directory
Single case management system
Report and monitor trends
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Ethics & Compliance Investigations
Executive Director, Ethics & Compliance
Investigations
Director, National Special
Investigations Unit (NSIU)
Sr. Manager, Enterprise Regional Compliance: Care
Delivery & Pharmacy
Analyst(4)
Manager(3)
Senior Investigator
(11)
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• Extensive and diverse experience in the investigation of criminal wrongdoing in public (law enforcement) and private sectors:
--Health Care Fraud --Criminal Investigations--Medicare Fraud --Drug Trafficking--Medicaid Fraud --Claims Review--Financial Crimes --Sex Crimes--Internal Revenue Service Audits --Terrorism Task Force
• Receive ongoing specialized training from recognized professional anti-fraud organizations.
• Participate in health care fraud task forces, including the joint law enforcement / private sector task forces sponsored by the U.S. Attorney's Offices.
Experienced Investigators
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When to Consult with NSIU
Our company
• Potential harm to KP• Potential harm to our
members, staff or the public
• Reputation issues• Potential media
exposure
Financial Impact
• Dollar loss over $10,000
Government
• Outside agency involvement (regulators)
• Legal implications• Potential criminal
implications• Contacted by law
enforcement
Regulators Law Enforcement
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• Fraud, Waste and Abuse (FWA) Allegations (over $10,000)• Pharmacy Theft / Drug Diversion • Member Fraud• Identity Theft• Health Care / Claims Fraud• Privacy / Computer Fraud
• Cash / Check Fraud• Embezzlement • Vendor Fraud • Kickbacks• Major Crimes
637 cases opened in 2017
National Special
Investigations Unit
Which of the categories below, represents 49 % of our cases?
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Partnership
• Internal Audit • Legal• Pharmacy• Regions• HR
Agile
• Training• Referrals• Annual work plan• Risk assessment• Request for Information (RFIs)
Our success
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Source https://oig.hhs.gov/newsroom/media-materials/2018/takedown/
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# of RFIs process
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How many RFIs do you think our team processed in 2018?
A.1050
B.1189
C.1425
D.1579
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Preparing for a CMS Audit
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Integrate Systemness
Ethics and Compliance Investigations and Operations coordinate Kaiser Permanente’s responses that are managed by the Ethics and Compliance Medicare Health Plan team.
• Medicare Monitoring Program (Medicare requirements metrics that measure operational performance outcomes).
• Audits: Compliance Program Effectiveness, Medicare Advantage Organizations (MAOs) and Medicare Prescription Drug Plan (PDP) functional areas.
• Centers for Medicare & Medicaid Services (CMS) regulatory and sub-regulatory guidance communication and tracking (i.e., new CMS issuances).
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How to respond to CMS memos and issuances
How clinicians partner with NSIU to submit referrals to National Benefit Integrity Medicare Drug Integrity Contractor (NBI MEDIC)
How to prepare the tracer during a CMS audit
Topic 6
Learning Objectives
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Compliance and Fraud, Waste, and Abuse Data Mining
Proactive
Reactive
CMS Memos
Three-pronged approach
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Receive CMS memos
and alertsDocument
the processClose the
loop through referrals
Partner with Pharmacy
Benefit Manager (PBM)
Merge disparate data
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Receive CMS memos
and alerts
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Document the process
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Data Visualization
List of pharmacies
List of providers
Prescription drug event
claims
596 pharmacies x 56 data elements = 33,376 total data elements.
Merge disparate
data
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March 2016 Data Visualization
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Merge disparate
data
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March 2016 Data Visualization
Find the Nugget
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Merge disparate
data
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After reviewing the data, we found a non-Kaiser Permanente provider writing for our Medicare members with an average of 770mg morphine equivalent dose / day prescription dispensed from a non-Kaiser Permanente pharmacy.
Non-Kaiser Permanente provider.
Non-Kaiser Permanente pharmacy.
Concerning medical chart note.
Monthly prescriptions:
1. Methadone 10mg #140
2. Morphine ER 200mg #84
3. Oxycodone 30mg #56
3Merge
disparate data
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March 2016 Data Visualization
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Merge disparate
data
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March 2016 Data Visualization
4 Partner with Pharmacy Benefit Manager (PBM)
After reviewing the data and investigative information, we identified the following findings.
Top five medications:
1. Oxycodone 30mg
2. Oxycontin 80mg
3. Oxycodone/APAP 10-325
4. Clonazepam
5. Gabapentin
Link from nurse practitioner to MD.
Diagnosis code: M54.5 & M96.1 for lower
back pain, post-laminectomy syndrome.
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March 2016 Data Visualization
4 Partner with Pharmacy Benefit Manager (PBM)
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March 2016 Data Visualization
4Partner with Pharmacy Benefit Manager (PBM)
Pharmacist
Medicine & Surgery
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March 2016 Data Visualization
4Partner with Pharmacy Benefit Manager (PBM)
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March 2016 Data Visualization
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Close the loop through referrals
NBI MEDIC referral
PLATO®
entry
PBM referral and
termination
HFPP*
entry
* Healthcare Fraud Prevention Partnership
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March 2016 Data Visualization
5The NBI MEDIC is currently investigating pharmacy, NPI 1942494166.• This investigation was opened as the result of a
Kaiser Permanente referral.• The NBI MEDIC is requesting any records or
notes obtained as part of the investigation.
SIRIS entry
NBI MEDIC investigation
RFI received
Criminal Investigation
NBI MEDIC informed KP about the providers. • Seven patients 60 years old or younger died of an
opioid overdose under physician care.• Two patients 60 years old or younger died of an
opioid overdose under nurse care.
On June 2017, the ‘pharmacy’ was terminated from Kaiser Permanente’s pharmacy benefit management (PBM).
Close the loop through referrals
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What should plan sponsors do?
Fill it out.
Complete three separate timelines.
Provide supporting documentation:
1. Training2. Communication
Engage subject matter experts.
How to Prepare the Tracer during a CMS Audit
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What should plan sponsors do?
Fill it out (10 Pages):
1. Background and issue2. Prevention3. Detection and reporting4. Correction
How to Prepare the Tracer during a CMS Audit
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What should plan sponsors do?
Fill it out.
Complete three separate timelines.
How to Prepare the Tracer during a CMS Audit
Timeline One – Overview Timeline Two – Beneficiary Level Timeline Three – PBM
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What should plan sponsors do?
Fill it out.
Complete three separate timelines.
Provide supporting documentation:
1. Training2. Communication
How to Prepare the Tracer during a CMS Audit • Delivered 27 drug-seeking
behavior trainings with 1,775+ attendees during the audit period
• CMS fraud, waste, and abuse webinar September 13, 2016
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Preparing for a CMS Audit
Key Takeaways
Process for responding to
CMS memos and issuances
Importance of clinician and
SIU partnership related to
NBI MEDIC referral
Steps taken to prepare for
CMS tracer audit
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Building a nimble and audit ready special investigations unit (SIU)
Key Takeaways
Integrate systemness Form strong partnership Selecting the right people
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Questions?
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[email protected] (510) 271-6937
[email protected] (408) 366-4554
[email protected] (562) 833-2391