DSDSDSDSQuality Assurance UnitQuality Assurance Unit

State of Alaska, Dept. of Health and Social ServicesDivision of Senior and Disabilities Services (DSDS)

Quality Assurance Unit 3601 C Street, Suite 310, Anchorage, Alaska 99503

Fran Arseneau, CPC, ManagerQuality Assurance Unit

Division of Division of Senior and Disabilities Services Senior and Disabilities Services

Medicaid Waivers: Adults with Physical Disabilities, Children Medicaid Waivers: Adults with Physical Disabilities, Children with Complex Medical Conditions, Developmental Disabilities, with Complex Medical Conditions, Developmental Disabilities, Older AlaskansOlder Alaskans

Personal Care Programs: Agency Based and Consumer DirectedPersonal Care Programs: Agency Based and Consumer Directed Skilled Nursing FacilitiesSkilled Nursing Facilities Developmental Disabilities Grant ProgramsDevelopmental Disabilities Grant Programs Senior Care Senior Information OfficeSenior Care Senior Information Office Senior Grant ProgramsSenior Grant Programs Adult Protective ServicesAdult Protective Services

The DSDS Quality Assurance ProgramThe DSDS Quality Assurance Program

The Quality Assurance (QA) Unit is the lead DSDS The Quality Assurance (QA) Unit is the lead DSDS unit responsible for ensuring the provision of unit responsible for ensuring the provision of consumer focused quality services and leads the consumer focused quality services and leads the Division’s efforts toward continuous improvement Division’s efforts toward continuous improvement of services provided to consumers. of services provided to consumers.

The QA Unit is also responsible for DSDS Program The QA Unit is also responsible for DSDS Program Integrity.Integrity.

DSDS Quality Assurance ActivitiesDSDS Quality Assurance Activities

Informing consumers of their rights and responsibilitiesInforming consumers of their rights and responsibilities

Collecting feedback on the quality of services providedCollecting feedback on the quality of services provided

Providing technical assistanceProviding technical assistance

Collaborating with other DSDS units in the implementation of a Collaborating with other DSDS units in the implementation of a DSDS quality assurance plan DSDS quality assurance plan

Influencing and supporting DSDS quality improvement initiativesInfluencing and supporting DSDS quality improvement initiatives

Responding to and investigating complaints of inappropriate Responding to and investigating complaints of inappropriate service provision or non-compliance with program guidelinesservice provision or non-compliance with program guidelines

Evaluating program performance through surveys andEvaluating program performance through surveys and auditsaudits

Quality Assurance Audit Activities Quality Assurance Audit Activities

Audit ObjectivesAudit Objectives

To evaluate provider and/or recipient compliance with Medicaid and Grant program To evaluate provider and/or recipient compliance with Medicaid and Grant program rules and regulationsrules and regulations

To safeguard recipient health and welfareTo safeguard recipient health and welfare

To ensure recipients have access to servicesTo ensure recipients have access to services

To evaluate provider capacities and capabilitiesTo evaluate provider capacities and capabilities

To ensure recipients understand their rights and responsibilitiesTo ensure recipients understand their rights and responsibilities

To evaluate outcomes and recipient satisfactionTo evaluate outcomes and recipient satisfaction

To identify and quantify questionable billing practices or program utilization patternsTo identify and quantify questionable billing practices or program utilization patterns

To assist the DSDS Policy and Program Review leadership in developing policies and To assist the DSDS Policy and Program Review leadership in developing policies and proceduresprocedures

To identify areas for Program improvementsTo identify areas for Program improvements

Program Audit ProcessProgram Audit Process One purpose of a program audit is to evaluate One purpose of a program audit is to evaluate

compliance with applicable statutes, regulations, compliance with applicable statutes, regulations, certification requirements, compliance with the certification requirements, compliance with the Medicaid provider agreement and applicable Medicaid provider agreement and applicable Medicaid provider billing manuals.Medicaid provider billing manuals.

Another purpose of a program audit is to provide Another purpose of a program audit is to provide information and data to assist DSDS in developing information and data to assist DSDS in developing and implementing regulatory and policy and implementing regulatory and policy guidelines that improve fiscal accountability and guidelines that improve fiscal accountability and quality of services.quality of services.

The Audit ProcessThe Audit Process

Audit ProcessAudit Process

Select the SampleSelect the Sample- Must be statistically validMust be statistically valid- May be based on provider or recipient sampleMay be based on provider or recipient sample

Notify and request recordsNotify and request records- May be initiated without notice May be initiated without notice

Evaluate the recordsEvaluate the records- Do the records meet standards?Do the records meet standards?

Document initial findingsDocument initial findings Notify regarding initial findings and additional record Notify regarding initial findings and additional record

reviewreview- Provide chance to comment and/or provide additional Provide chance to comment and/or provide additional

documentationdocumentation Amend the findingsAmend the findings Reconcile amended findingsReconcile amended findings

Reconciliation of FindingsReconciliation of Findings

Provider/Recipient educationProvider/Recipient education

Corrective Action PlansCorrective Action Plans

Recommendations for program and/or Recommendations for program and/or policy improvementspolicy improvements

Referrals to other entities or for Referrals to other entities or for implementation of sanctionsimplementation of sanctions

COMMON FINDINGSCOMMON FINDINGS

Un-documented servicesUn-documented services Inadequate or deficient recordsInadequate or deficient records Program violations such as family/guardians providing Program violations such as family/guardians providing

services, client rights ignored or violatedservices, client rights ignored or violated Licensure or certification violationsLicensure or certification violations Inappropriate billing practices (i.e., incorrect procedure Inappropriate billing practices (i.e., incorrect procedure

codes and/or modifiers, duplicate claims payments)codes and/or modifiers, duplicate claims payments) Duplicate claims paymentsDuplicate claims payments Deficient or non-existent financial recordsDeficient or non-existent financial records Inaccurate provider certification or Medicaid enrollment Inaccurate provider certification or Medicaid enrollment

informationinformation

PROGRAM/POLICY IMPROVEMENTSPROGRAM/POLICY IMPROVEMENTS

System problems identifiedSystem problems identified

Medicare cross over claims processingMedicare cross over claims processing

Provider specific assistanceProvider specific assistance

Focused training needsFocused training needs

Policy and program reviewPolicy and program review

Appeals issuesAppeals issues

AUTHORITYAUTHORITY

Health Information, Portability and Accountability Act of 1996Health Information, Portability and Accountability Act of 1996

HIPAA provides exception for state access to Private Health HIPAA provides exception for state access to Private Health Information for:Information for:

– Audits, monitoring, and licensing & certification - 45 CFR Audits, monitoring, and licensing & certification - 45 CFR 160.203160.203

– Protects whistleblowers - 45 CFR 164.502(j)Protects whistleblowers - 45 CFR 164.502(j)– Permits PHI disclosure for:Permits PHI disclosure for:

AuditsAudits InvestigationsInvestigations InspectionsInspections Licensure or disciplinary actionsLicensure or disciplinary actions Civil, administrative, or criminal proceedingsCivil, administrative, or criminal proceedings Other Government functions authorized by lawOther Government functions authorized by law 45 CFR 164.512 (a) & (d)45 CFR 164.512 (a) & (d)

FEDERAL AUTHORITIESFEDERAL AUTHORITIES

42 CFR part 431 – State Organization and General 42 CFR part 431 – State Organization and General AdministrationAdministration

42 CFR Part 455 – Program Integrity: Medicaid42 CFR Part 455 – Program Integrity: Medicaid 42 CFR Part 456 – Utilization Control42 CFR Part 456 – Utilization Control 42 CFR Part 1002 – Program Integrity 42 CFR Part 1002 – Program Integrity Health Insurance Portability Accountability Act (HIPAA) 1996Health Insurance Portability Accountability Act (HIPAA) 1996

STATE AUTHORITIESSTATE AUTHORITIES AS 47.05.021 Medical Assistance Fraud AS 47.05.021 Medical Assistance Fraud AS 47.07.074 Audits and Inspections AS 47.07.074 Audits and Inspections 7 AAC 43.005 to 1990 Alaska Medicaid Regulations7 AAC 43.005 to 1990 Alaska Medicaid Regulations

– 7 AAC 43.027 Restriction of Recipient Choice of Providers7 AAC 43.027 Restriction of Recipient Choice of Providers– 7 AAC 43.030 Requirements for Provider Records7 AAC 43.030 Requirements for Provider Records– 7 AAC 43.032 Request for Records7 AAC 43.032 Request for Records– 7 AAC 43.035 Eligible Providers7 AAC 43.035 Eligible Providers– 7 AAC 43.065 Medical Provider Agreement7 AAC 43.065 Medical Provider Agreement– 7 AAC 43.067 Reviews and Audits7 AAC 43.067 Reviews and Audits– 7 AAC 43.068 Use of Statistical Sampling7 AAC 43.068 Use of Statistical Sampling– 7 AAC 43.081 Recovery of an Overpayment7 AAC 43.081 Recovery of an Overpayment– 7 AAC 43.085 Provider Appeals7 AAC 43.085 Provider Appeals– 7 AAC 43.950 Grounds for Sanctioning Providers7 AAC 43.950 Grounds for Sanctioning Providers

MEDICAID WAIVER AUTHORITYMEDICAID WAIVER AUTHORITY

Federal Assurances Federal Assurances 1915 (c) Medicaid Waiver Assurances1915 (c) Medicaid Waiver Assurances State RegulationState Regulation 7 AAC 43.1000 to 1110 Medical Home and Community-7 AAC 43.1000 to 1110 Medical Home and Community-

Based Waiver ServicesBased Waiver Services

Resources On the WebResources On the Web

State of Alaska: State of Alaska: http://www.state.ak.ushttp://www.state.ak.us

Division of Senior and Disabilities Services: Division of Senior and Disabilities Services: http://http://www.hss.state.ak.us/dsdswww.hss.state.ak.us/dsds

Division of Health Care Services: Division of Health Care Services: http://www.hss.state.ak.us/dhcshttp://www.hss.state.ak.us/dhcs

First Health Services Corporation First Health Services Corporation http://http://alaska.fhsc.comalaska.fhsc.com

Department of Law - Medicaid Fraud Control Unit Department of Law - Medicaid Fraud Control Unit http://www.law.state.ak.us/criminal/ospa/medfraudhttp://www.law.state.ak.us/criminal/ospa/medfraud

Resources On the WebResources On the Web

State of Alaska - Statutes and Regulations State of Alaska - Statutes and Regulations http://www.legis.state.ak.us/folhome.htmhttp://www.legis.state.ak.us/folhome.htm

Centers for Medicaid and Medicare [CMS] - Medicaid Centers for Medicaid and Medicare [CMS] - Medicaid http://www.cms.hhs.gov.gov/medicaidhttp://www.cms.hhs.gov.gov/medicaid

OIG - Compliance Guidance For Individual, Small Group OIG - Compliance Guidance For Individual, Small Group Practices Practices http://www.hhs.gov/oig/modcomp/cpc.pdfhttp://www.hhs.gov/oig/modcomp/cpc.pdf

Questions ??Questions ??

Fran Arseneau, CPC, Manager

Quality Assurance Unit

(907) 269-3654

Fran_Arseneau@health.state.ak.us