Medicaid Integrity Program State PI Reviews CMS Medicaid Integrity Group Division of Field Operation

1
Medicaid Integrity Program State PI
ReviewsCMS Medicaid Integrity Group Division
of Field Operations

• 23rd Annual NAMPI Conference
• Coronado, CA
• August 28, 2007

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Deficit Reduction Act of 2005 MIP Statutory
Requirements

• Created Medicaid Integrity Program (MIP)
• Contracts for Claims Review, Audits, Overpayment
  Identification Education
• Effective Support and Assistance to States

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Effective Support AssistanceFour Primary
Strategies

• Fraud research
• Investigative support coordination
• Training technical assistance
• PI Institute CPT coding SMDs etc.
• State program integrity assessments
• State PI reviews
• PI metrics

4
DFO Staffing

• Key administrative roles
• Deputy Directors in NY SF
• Coordinators for provider audits, policy, law
  enforcement and state PI reviews
• Medicaid Integrity Specialists
• Hiring in progress
• Variety of skills/backgrounds
• Basic training including state PI operations
• Possible state PI internships

5
MIS Responsibilities

• All PI reviews
• State PI liaisons for training technical
  assistance
• Audit results coordination

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Division of Field Operations

• 30 Medicaid Integrity Specialists assigned to one
  of 5 field offices
• NYC ROs I/II
• Atlanta ROs III/IV
• Chicago ROs V/VII
• Dallas ROs VI/VIII
• San Francisco ROs IX/X

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Medicaid Alliance for Program Safeguards

• MAPS
• Limited resources
• Relied on regional office staff and unpredictable
  travel funds
• Evolving process
• 45 reviews of 44 states between FY00 FY 06

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MAPS Reviews

• 23 states were in regulatory non-compliance 21
  states no problem
• Inconsistent follow up
• Confidential reports
• Annual national summary

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MIP Review GoalsMake one states best practices
every states common practices

• Statutory regulatory compliance
• Identification of best practices
• NY post clear
• Vt 100 annual recert of provider
• Identification of vulnerabilities
• Numerous states poor MFCU relations
• MIG developing referral performance standards
• Opportunities for technical assistance
• Improve Medicaid PI nationally

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MIP Reviews

• 3 types of program integrity reviews
• Focused (e.g. Medi-Medi readiness)
• Corrective action follow ups
• Comprehensive
• States will be on 3 year comprehensive review
  cycle
• Other reviews as appropriate
• Public reports

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Comprehensive Review Process

• 8 weeks notice of onsite review
• State material due 30 days in advance of onsite
• 3-4 CMS staff onsite for one week
• Interview all key staff, including MCOs MFCU
• Review guide continues to evolve
• Qualitative judgments

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States Under Review

• FY 07 CT, MI, NV, AR, DE, VA, MO, OR
• FY 08 GA, IL, IA, MN, NM, NC, ND, OK, PA, PR,
  SC, SD, TN, TX, UT, VT, WY
• OIG OEI Evaluation

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Frequent IssuesAll Reviews Through July 2007

• 42 CFR 455.106
• Provider disclosure of criminal convictions
• 22 states
• State discretion to disqualify provider
• 42 CFR 455.104
• Provider disclosure of ownership info
• 13 states
• FFP not available for non-responsive providers

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Frequent Issues (cont)

• 42 CFR 455.106
• States reporting adverse actions to OIG
• 9 states
• OEI study near completion
• 42 CFR 455.105
• Provider disclosure of business transactions
• 7 states
• Potential loss of FFP for non-responsive
  providers

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Questions?

• Robb Miller
• 312-353-0923
• Robb.miller_at_cms.hhs.gov
• For copy of PI Review Guide
• Pamela.howard_at_cms.hhs.gov