An Investigative Journey ( Follow the Money) Mary Wanager, RN Analyst Monique Loh, LCSW Analyst DMA...
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An Investigative Journey (Follow the Money) Mary Wanager, RN Analyst Monique Loh, LCSW Analyst DMA Program Integrity Behavioral Health Review Section
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Transcript of An Investigative Journey ( Follow the Money) Mary Wanager, RN Analyst Monique Loh, LCSW Analyst DMA...
An Investigative Journey(Follow the Money)
Mary Wanager, RN AnalystMonique Loh, LCSW Analyst
DMA Program Integrity Behavioral Health Review Section
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o Increase knowledge of claims analysis.
o Improve decision making skills related to PI investigations.
o Best practices for writing an MID referral.
OBJECTIVES
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FOLLOW THE MONEY
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Purpose of the Journey:Chain of Authority
42 CFR 455.2 Fraud is an intentional deception that results in some
unauthorized benefit.
Abuse are practices that are inconsistent with sound fiscal practices and result in unnecessary cost to Medicaid.
Mistakes are errors made by a provider resulting in overpayment.
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Chain of Authority
42 CFR §455.14 State Medicaid agency is mandated to conduct a
preliminary investigation and identify questionable practices for fraud or abuse complaint.
42 CFR §455.15 State Medicaid agency is mandated to refer the provider
to the Medicaid Fraud Control Unit (MFCU) for possible Medicaid fraud based on preliminary investigation results.
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Chain of Authority
Health Care Fraud (18 U.S.C. §1347)
False Claims Act (31 U.S.C.§3729-3733)
False Claims (NCGS 108A-70.10 thru 70.17)
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Chain of Authority
NC Administrative Code 22F (Program Integrity)
Medicaid Clinical Coverage Policies
Medicaid Provider Participation Agreement
MCO Contract with Provider
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Before We Start the Journey…
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Before We Start the Journey…
Routine Monitoring
o Global Review
o Tools with Specific Questions
o Specified Time Intervals
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Before We Start the Journey…
Complaint Investigation
o Limited Scope
o Complaint Driven Review
o Limited Analytics
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Before We Start the Journey…
Program Integrity Investigation
o Mandated by Federal and State Statutes
o Driven by Complaint and/or Data Analytics
o Claims Analysis Shapes Focus of Review
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Before We Start the Journey…
Program Integrity Investigation
o Comprehensive Research and Planning
o Larger Sample Size and Scope
o Unannounced Onsite Investigation
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Starting Point:Finding Leads in Referrals
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Referral #1
XYZ MCO received a Fraud Hotline email from Ms. Jones on 6/30/14. She alleged that Alpha 2 Omega Counseling Services might be billing without rendering services. On 1/2/14, she signed up for counseling with this provider and received an assessment on 1/10/14 that lasted only 30 minutes. She is currently seeing Ms. Ali Bai for individual therapy.
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Referral #2
Errol Flynn alleged that A Brand New You Incorporated was committing fraudulent billing. As a former employee, he reported that Dee Lusion (owner) routinely asked him to bill ACTT and outpatient services for clients who had unused units from a prior authorization. He also reported that employees were instructed to make up service notes. Mr. Flynn left a telephone number and address in his voicemail on the MCO Fraud Hotline.
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Planning for the Journey:Quest for Information
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Planning for the Journey:Quest for Information
o Follow up with the complainant or caller
o Collaborate with your MCO peers o Collaborate with other MCO especially if this is a CABHA or PRTF
provider
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Quest for Information
o Prior PI and/or MID involvement
o NC Professional Boards for license verification
o Billing and Attending Provider’s websites
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Quest for Information
o NC Secretary of State and Office of Inspector websites:
http://www.secretary.state.nc.us/corporations/csearch.aspx http://exclusions.oig.hhs.gov
o Public Record Metasites http://www.searchsystems.net http://www.blackbookonline.info
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Quest for Information
o Allegation Package/FAMS reports
o Data Analytics from PI staff
o Driving by the provider’s office at different times
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Follow the Money Trail:Claims Analysis
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Follow the Money Trail:
Claims Analysis Claims Analysis is examining paid claims to ascertain patterns of suspicious billing that
warrants further investigation for possible Medicaid fraud.
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Follow the Money Trail:
Claims Analysis o Expand paid claim analytics to include other services
o Expand complainant to a larger group of recipients
o Expand dates of service to a wider span of time
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Follow the Money Trail:
Claims Analysis o Excessive regularity of billing
o Billing exceeding 24 hours a day
o Possible unbundling of family or group therapy
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Follow the Money Trail:
Claims Analysis o Backfiling
o Billing time limited service for extended period of time
o Billing mutually exclusive services on same date of service
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Follow the Money Trail:Claims Analysis
o Billing very young recipients with questionable diagnosis
o Routine billing of concurrent services
o Same attending provider for all paid claims
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Claims Analysis Reminder
o Focus on the NPI number linked
to the paid claims
o Attending provider may not
know that billing provider is
using his/her NPI number
o Consider possible identity theft
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Follow the Money Trail:Claims Analysis
o Cookie cutter diagnosis for all beneficiaries
o Excessive use of assessment service codes
o Long distance between place of service and beneficiaries’ home addresses
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Follow the Money Trail:Claims Analysis of the Less Family
Annie Mossity reported that she saw two men have been knocking on doors in her apartment building. She noted that they drive a brand new Cadillac Escalade. The men usually gave away bags of goodies to the children in the neighborhood. As a matter of fact, her next door neighbors, Ruth and Grace Less (grandmother and mother), signed all the children up for services with the Doolittle & Plunder Behavioral Health Services in June. The grandmother was especially relieved that the agency van picked up the grandchildren everyday for the summer camp. She told Ms. Mossity that she finally got what she prayed for, a time of rest from childcare.
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Fork in the Road: Desk or Onsite Audit
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Fork in the Road: Desk Review if…
o Self Audit with Payback
o Quality of Care
o Limited Scope
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Fork in the Road: Onsite Review if…
o Billing Anomalies
o Falsification of Medical Records
o Misuse of Beneficiary’s Funds
o Solicitation and/or Kickbacks
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Road Map to the Money Targeted Review
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Road Map to the Money Targeted Review
o Know what you are looking for
o Track the complaint and claims analysis
o Random samples will not yield a productive investigation
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Road Map to the Money Targeted Review
o Claims research to identify aberrant billing patterns
o Aberrant billing patterns are the money trails
o Target reviews to maximize recovery of overpayments
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Road Map to the Money Targeted Review
Examples of Targeted Reviews:
o Families of multiple siblings billed on same dates of service
o Beneficiaries billed on provider’s busiest work day
o Beneficiaries with highest dollar amount
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Road Map to the Money Targeted Review
Examples of Targeted Reviews
o Young beneficiaries with questionable diagnosis
o Beneficiaries with questionable place of service
o Beneficiaries identified in the referral or complaint
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Highlight of the Journey:Unannounced Onsite Audit
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Highlight of the Journey:Unannounced Onsite Audit
Advantages of Onsite Audit
o Element of Surprise
o Observations of the provider’s office and its milieu
o Interactions with staff and/or beneficiaries
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Highlight of the Journey:Unannounced Onsite Audit
Observe
o Physical site including business signs and parking lot
o How provider and staff respond to audit
o How provider and staff accommodate PI team’s requests
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Highlight of the Journey:Unannounced Onsite Audit
Observe
o Increased activity around the front office
o Client and staff flows in the common areas
o Submission of documentation
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Highlight of the Journey:Unannounced Onsite Audit
Interview Key Staff
o Billing process
o Oversight of Finance
o Staff Supervision
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Highlight of the Journey:Unannounced Onsite Audit
Interview Key Staff
o Quality Assurance
o Supervision for Provisionally Licensed Staff
o Oversight of Service Documentation
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Highlight of the Journey:Unannounced Onsite Audit
Interview Key Staff
o Organizational Chart
o Service Orders and Authorizations
o Storage of Documentation
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Highlight of the Journey:Unannounced Onsite Audit
Interview Therapist or Team Lead
o Routines of a Typical Work Day
o Working with client from start to finish
o Collaboration with Physician and Administrative Staff
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Highlight of the Journey:Unannounced Onsite Audit
Interview Therapist or Team Lead
o Clinical challenges including treatment noncompliance
o Best Practice Model used
o Crisis Coverage Plan
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Highlight of the Journey:Unannounced Onsite Audit
Documentation Requests:
o Scan entire medical records of all sample beneficiaries
o Organizational Charts for all sites
o Policy and Procedures for the agency and electronic documentation
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Highlight of the Journey:Unannounced Onsite Audit
Documentation Requests:
o All personnel files and time sheets for employees related to the complaint
o Team composition for the enhanced services
o Address and phone number for the storage site
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Highlight of the Journey:Unannounced Onsite Audit
Documentation Requests:
o Signed statement verifying submission of all medical records
o Appointment schedules for therapists and physician
o Sign in sheets for clients
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Another Fork in the Road: Decision Making
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Another Fork in the Road:Decision Making
Recoupment:
o Staff Qualification Issues
o Lapses in Staff License or Agency Accreditation
o Lack of Intentional Misconduct
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Another Fork in the Road:Decision Making
Recoupment:
o Documentation Deficiencies Only
o No Evidence to Support Complaint or Allegation
o Need for Provider Training
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Another Fork in the Road:Decision Making
MID Referral
o Evidence of credible allegation of fraud
o Evidence is corroborated by investigative findings
o Evidence is supported by claims analysis
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Another Fork in the Road:Decision Making
Corroboration is “often found in a pattern of aberrant behavior. Examples include significant numbers of identical clinical notes or large numbers of missing medical records without legitimate explanation. Data analysis examples include a pattern of excessive routine billing and repeatedly billing for multiple members of a family on the same date of service.”
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Another Fork in the Road:Important Reminder
Referring a provider to DMA PI for possible Medicaid fraud and initiating an administrative recoupment at the same time is NOT RECOMMENDED. Recoupment and/or reporting the provider to appropriate professional boards can compromise a MID investigation down the road.
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Putting the Pieces Together:Writing An Effective MID Referral
Minimum Criteria for MID Referral by CMS(Centers for Medicare and Medicaid Services)
o Allegation
o Financial Information
o Investigative Findings
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Putting the Pieces Together:Writing An Effective MID Referral
o Narrative Summary o Claims Data
o Specific Medicaid Statutes and Policies Violated
o Other Investigative Findings
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Putting the Pieces Together:Writing An Effective MID Referral
o State only the facts and findings
o Proof reading by supervisor and/or peer
o Strunk & White’s “Elements of Style” for grammatical guidance
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Putting the Pieces Together:Writing An Effective MID Referral
o Microsoft Word 2010 for spell check, editing passive voice and readability level
o Redact all personal identifiers for beneficiaries receiving substance abuse service/diagnosis.
o Two encrypted CDs with claims data
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Putting the Pieces Together:Writing An Effective MID Referral
Important Reminders:
o PI staff must conduct an investigation (at least a desk review) before submitting a referral to DMA
o If it is NOT DOCUMENTED, it is not DONE.
o KISS (Keep it Simple Stupid)
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Grand Finale:Group Assignment
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Grand Finale:Group Assignment
o Identify An Investigation Plan
o Create Investigative Evidences
o Bullet Evidences for MID Referral
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End of the Journey
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WHAT ARE YOUR QUESTIONS
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Contact
Mary Wanager, RN Analyst (919) 814-0109
Monique Loh, LCSW Analyst (919) 814-0131
DMA-Program Integrity BHRSWebsite: http://www.ncdhhs.gov/dma
Fax: 919-814-0035
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