METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER LEFT BEHIND - PowerPoint PPT Presentation

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METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER LEFT BEHIND

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METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER LEFT BEHIND James G. Sheehan Medicaid Inspector General – PowerPoint PPT presentation

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Title: METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER LEFT BEHIND


1
METRO CHAPTER HFMA JOSEPH A. LEVI ANNUAL
INSTITUTE ELMHURST, NY 3/11/11 OMIG-NO PROVIDER
LEFT BEHIND
  • James G. Sheehan
  • Medicaid Inspector General
  • James.Sheehan_at_OMIG.NY.GOV

2
2011-Governor Cuomo New York is at a crossroads
  • Budget challenges-9-10 billion deficit
    projection
  • MRT (Medicaid Redesign Team)
  • 79 agreed-upon Medicaid proposals now before
    Legislature
  • Budget deadline-April 1

3
CORE QUESTIONS IN PROGRAM INTEGRITY
  • How do we determine whether NY Medicaid and its
    patients get the services it is paying for?
    (actually rendered, ordered, needed, documented,
    minimum quality)
  • Do NY Medicaid providers comply with their
    contractual requirements for payment?
  • How do we identify the providers most likely to
    fail in their compliance and patient care
    obligations?
  • What we do with these identified providers?

4
How do we determine whether NY Medicaid and its
patients get the services it is paying for?
  • Existing approaches
  • Field audits/desk audits (is there a physician
    order for the service? Is there a record the
    patient actually received the service?)
  • Data matches-billing for deceased patients,
    billing for home health during hospital stay
  • Third party payor reviews-are we paying for
    something someone else should pay for?

5
How do we determine whether NY Medicaid and its
patients get the services it is paying for?
  • Newer approaches
  • Clinical audits-do the services rendered and
    billed map against patient assessment and
    treatment plan of care? Why are patients with no
    prior diabetes diagnosis getting test strips? Has
    a physician who ordered 10 million in home
    health services actually seen and treated the
    patients for whom services are ordered?

6
How do we determine whether NY Medicaid and its
patients get the services it is paying for?
  • Newer approaches
  • Data analysis on third party claim payment
    information received from private payors and
    Medicare
  • Who got paid twice
  • Who charged us after payment in full by private
    payor
  • Who kept the money?

7
How do we determine whether NY Medicaid and its
patients get the services it is paying for?
  • Newer approaches
  • Medicaid Integrity Contractor (required by feds)
  • Medicaid RAC (required by feds)
  • Salient data mining
  • Geographic mapping
  • Time mapping
  • Network analysis
  • Claim denial analysis

8
Do NY Medicaid providers comply with their
contractual requirements for payment?
  • Credentials Verification Reviews
  • Licenses, cons
  • Certifications
  • Excluded persons ordering or providing
  • Real addresses, real owners, service provided by
    billing entity?
  • Doctor flophouses rented by week
  • Service bureaus

9
How do we identify the providers most likely to
fail in their compliance and patient care
obligations?
  • Investigators technique ask them when you
    already know the answer
  • Compliance technique testing
  • No provider left behind

10
THE OMIG STORY-NO PROVIDER LEFT BEHIND
  • New Yorks Mandatory Compliance Program
  • Every Medicaid provider which receives or orders
    more than 500,000 in Medicaid reimbursed
    services must have an effective compliance
    program including 8 elements
  • Every Medicaid provider subject to requirements
  • As of October 1, 2009 must have effective
    compliance program
  • As of December 31, 2009 must certify that it has
    an effective compliance program

11
THE OMIG STORY-NO PROVIDER LEFT BEHIND
  • Every Medicaid provider which receives or orders
    more than 500,000 in Medicaid reimbursed
    services in 12 months must have an effective
    compliance program including 8 elements

12
FIRST COMPLIANCE YEAR-2010-EASY EXAM-SIGN YOUR
NAME, SCORE 100
  • Every Medicaid provider subject to requirement
    must certify during December 2009 that it has an
    effective compliance program

13
HOW DID NY PROVIDERS DO ON THE EASY EXAM?
  • AS OF APRIL 1, 2010, THREE MONTHS AFTER THE
    REQUIRED SIGN YOUR NAME, GET 100 Exam. . .

14
HOW DID NY PROVIDERS DO ON THE EASY EXAM?
  • 50 flunked!

15
Options when 50 flunk no provider left behind
  • Blame the students (providers)
  • Blame the teachers (OMIG)
  • Blame the parents (Board, CEO)
  • Figure out how to do better

16
EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL
TELL YOU THE ANSWER-GIVE IT BACK TO US
  • Letters to every non-certifying provider over
    500,000 per year
  • Personal visits and phone calls
  • Webinars and trade association presentations
  • Detailed website instructions, discussion of
    consequences of non-certification
  • Extended deadline to October 1
  • What happened?

17
EASY EXAM-YOU FLUNKED THE FIRST TIME, WE WILL
TELL YOU THE ANSWER- JUST GIVE IT BACK TO US
  • 20 still flunked!

18
SECOND COMPLIANCE EXAM-2011-EASY EXAM-SIGN YOUR
NAME, READ OUR CHEAT SHEET AND FOLLOW IT, SCORE
100
  • Show me the cheat sheet . . .

19
New York Eight Elements of Compliance Program
Certification of Compliance
  • New York State Social Services Law Section
    363-d.Subsection 2
  • Certification by December 31 of each
    year-effective
  • 18 NYCRR Section 521.3 (c)
  • A compliance program shall include the following
    8 elements
  • Element 1 Written Policies and Procedures
  • Element 2 Designation of Compliance Officer
  • Element 3 Training and Education
  • Element 4 Communication lines to the
    Compliance Officer
  • Element 5 Disciplinary Policies
  • Element 6 Identification of Compliance Risk
    Areas and non-compliance
  • Element 7 Responding to Compliance Issues
  • Element 8 Policy of Non-Intimidation and
    Non-Retaliation

20
New York Compliance Measurement Tool
  • Cited by CMS as model
  • Available on OMIG website
  • www.OMIG.NY.Gov

21
2011 NEW YORK COMPLIANCE
  • How are we doing in 2011?
  • Somewhat better, but not as well as we hoped-even
    with organizations contacted in 2010
  • OMIG is now doing on-site compliance reviews to
    assess the compliance programs of specific
    providers
  • Start with good ones for modeling
  • Move to weaker ones for intervention

22
2011 NEW YORK COMPLIANCE
  • Universe of Providers by Provider ID paid or
    ordered over 1 million 19,885
  • Providers by Provider ID paid or ordered over 1
    million not certified (as of 3/10/11) 4,352
    (22)
  • Universe of Providers by Provider ID paid or
    ordered over 5 million not certified 234
  • Small number of ordered over 1 million

23
WHAT SHOULD OMIG DO WITH ORGANIZATIONS WHICH DO
NOT PASS THE EXAM?
  • If you cant pass an exam where you get a perfect
    score for signing your name, and we give you the
    correct answers, you probably arent doing a
    great job with your core health care mission or
    correct billing either
  • If you contract or have business relationships
    with organizations that do not or cannot certify,
    they may not be doing a great job with their
    contractual and care obligations to you and
    patients either

24
How else do we identify the providers most likely
to fail in their compliance and patient care
obligations?
  • Affordable Care Act Section 6402
  • Report, refund, and explain identified
    overpayments within 60 days of identification
  • Knowing failure to report False Claims Act
    violation
  • Zero is a bad number
  • 227 reports in 2010 is a good number
  • Use self-disclosure protocol on OMIG website

25
How else do we identify the providers most likely
to fail in their compliance and patient care
obligations?
  • If they cant pass the OMIG exam, which requires
    signing your name and reading the cheat sheet,
    how are they doing on the IRS exam?

26
IRS Form 990 Questions for Non-Profits on
Governance Policies
27
NEW YORK MEASURING COMPLIANCE PROGRAMS
  • Telephone calls
  • Please connect me with your compliance officer
  • How do you check for excluded persons among
    employees and contractors?
  • We have not received your certification could
    you send me a copy?
  • How often do you meet with the Board or a board
    committee?
  • Can we get a copy of your most recent IRS-990

28
How else do we identify the providers most likely
to fail in their compliance and patient care
obligations?
  • Relationship mapping of problem providers
  • And then what happened? followups to match
    projects, third party liability, audits for
    corrective action
  • Conflict and exception reports in home health
  • hotline

29
What can we do with the identified providers who
cannot meet their compliance obligations?
  • Call or write and ask why
  • Post names of non-certifiers
  • Reduce audit, investigative efforts on compliant
    organizations (and encourage other enforcement
    and regulatory entities to do so)
  • Terminate audits promptly where strong evidence
    of compliance
  • Increase audit, investigative, data analytic
    efforts on less compliant organizations
  • Look for common factors and relationships among
    less compliant providers (e.g., CEO indicted by
    US Department of Justice)

30
AUDITING EFFECTIVE COMPLIANCE PROGRAMS
  • Who is the compliance officer?
  • To whom do they report?
  • Do employees and vendors know about the
    compliance program?
  • Who does billing? How accurate is it?
  • Contingency fee contracting for coding and
    billing
  • FMV reviews of physician payments
  • Conflicts of interest
  • Relationships with non-profits and the IRS form
    990

31
OMIG PLANS TO INCREASE ITS FOCUS ON
COMPLIANCE-CHALLENGED ORGANIZATIONS
  • Audits
  • Data match followup
  • Salient analysis (geography, chronology,
    relationships)
  • Investigations
  • Exclusions

32
WHAT SHOULD BUSINESS PARTNERS DO WITH
ORGANIZATIONS WHICH DO NOT CERTIFY?
  • If you cant pass an exam where you get a perfect
    score for signing your name, and OMIG gives you
    the correct answers, you probably arent doing a
    great job with your core health care mission and
    your contractual and partner responsibilities
    either

33
WHAT SHOULD BUSINESS PARTNERS DO WITH
ORGANIZATIONS WHICH DO NOT CERTIFY?
  • Call or write and ask why
  • Raise issue to higher level in organization
  • Investigators technique ask them when you
    already know the answer
  • Compliance requirements
  • Element 6 Identification of Compliance Risk
    Areas and non-compliance
  • Element 7 Responding to Compliance Issues

34
FREE STUFF! www.omig.ny.gov
  • Model compliance programs-hospitals, managed care
    (coming soon) and Compliance Alerts
  • Over 2000 provider audit reports, detailing
    findings in specific industry
  • Annual work plans
  • New York excluded provider list
  • Self-Disclosure protocol
  • Corporate Integrity Agreements
  • Listserv
  • Link to sites for all 18 states which currently
    publish their state exclusion lists
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