Program Integrity Changes and Updates - VGM Heartland by wuyunyi

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									CHANGE IS IN THE AIR
      Understanding all the changes to
          Medicare Program Integrity


                    June 11, 2009
BACKGROUND - PROGRAM INTEGRITY
 • HIPAA - 1996
    – Medicare Integrity Program
       • Program Safeguard Contractors
 • Balanced Budget Act – 1997
    – Medicare Part C
 • Medicare Modernization Act - 2003
    – Prescription Drug Benefit
    – Medicare Contracting Reform
       • Medicare Administrative Contractors
BACKGROUND of ZPICs
• Deficit Reduction Act – 2005
   – Medicaid Integrity Program
   – Medicare-Medicaid (Medi-Medi) Data Match
     Program
• As a result of contracting reform, seven zones were
  created. As a result of the seven zones, new entities
  entitled Zone Program Integrity Contractors (ZPICs)
  have been created to perform program integrity for
  Medicare Parts A, B, C, D, DME, Home Health &
  Hospice, and Medi-Medi.
CURRENT PROGRAM INTEGRITY
ENVIRONMENT
      Part D                            Medicare Parts
     Program                              A and B
     Integrity                            Program
                                          Integrity

                            Medicare                      Medicare-
                            DMEPOS                        Medicaid
                            Program                      (Medi-Medi)
                            Integrity                      Program
     MEDICS                                                Integrity
                                         Program
                                        Safeguard
                  Part C                Contractor           Home
                 Progra                                     Health +
                 m                                           Hospice
                 Integrit                                   Program
                 y                                          Integrity
ZPIC FUTURE ENVIRONMENT


    Medicare             Home
    Parts A    DMEPOS    Health     Medi-Medi   Part C & D
     &B                 & Hospice




                        ZPIC
ZONES
1.   CA, NV, AS, GU, HI, Mariana Islands
2.   AK, WA, OR, MT, ID, WY, UT, AZ, ND, SD, NE, KS, IA,
     MO
3.   MN, WI, IL, IN, MI, OH, KY
4.   TX, OK, CO, NM
5.   WV, VA, NC, SC, GA, AL, MS, TN, AR, LA
6.   PA, NY, MD, DC, DE, ME, MA, NJ, CT, RI, NH, VT
7.   FL, PR, VI
                                           ZONE MAP
           WA



                                MT
                                                   ND

                                                                   M``N
     OR

                      ID                   2   SD
                                                                                 WI
                                                                                                                                    NY
                                     WY                                                          MI



          NV                                        NE                IA
                                                                                                                                         6
                                                                                                                           PA

                                                                                                               OH

     1                     UT         CO
                                                                                  IL


                                                                                            3
                                                                                             IN                      WV


CA                                                       KS                MO                                                  VA
                                                                                                      KY


                                                                                            TN
                                                                                                                                    NC

                                     NM                       OK
                     AZ                                                     AR                                            SC



                                                                                                 AL
                                                                                                           5        GA

                                               4   TX
                                                                                       MS



                                                                            LA


                AK



                                                                                                                           7
                                                                                                                                             PR
CYCLES
• Cycle One - Zones 4, 5, & 7
   – Awards made
      • Implementation was February 1, 2009
      • Health Integrity, LLC – Zone 4 ($84,929,432)
      • Safeguard Services, LLC – Zone 7 ($78,684,443)
      • AdvanceMed Corp – Zone 5 ($107,975.737 - UNDER
        PROTEST)
• Cycle Two - Zones 1 & 2
   – RFPs released on May 2, 2008
   – Anticipated award date was October 2008, but not yet
     announced
• Cycle Three – Zones 3 & 6
   – Anticipated award date is June 2009
   – RFPs not yet released
TASK ORDERS

 • Each Zone currently includes the following task
   orders:
    – A/B/DME/HH&H
    – Medi-Medi
 • Part C and Part D are not included in the first round
   of implementation
PURPOSE

 • It provides a vehicle to promote the integrity of the
   Medicare and Medicaid programs by accomplishing
   the following objectives:
    – Identify, stop, and prevent fraud, waste, and abuse
       and refer instances to the appropriate law
       enforcement agencies
    – Decrease the submission of fraudulent and
       abusive claims
PURPOSE

 • Recommend appropriate administrative action
    – Payment suspension
    – Civil Monetary Penalties
    – Exclusion
    – Revocation
 • Coordinate potential fraud, waste, and abuse with
   appropriate entities
FUNDAMENTAL ZPIC ACTIVITIES

 • Benefit Integrity Investigations
 • Referral of cases to law enforcement
 • Medical Review for Benefit Integrity functions
   including coverage and coding determinations
 • Review of audit, settlement, and reimbursement of
   cost reports
 • Reviewing bids for participation in the Prescription
   Drug Program (Part C and D only)
FUNDAMENTAL ACTIVITIES

 • Assisting CMS in developing a list of entities that may
   require future monitoring based upon past history
 • Conducting specified audits
 • Conducting specified complaint investigations (Part C
   and D only)
 • Conducting preliminary investigations into entities
   conducting fraudulent enrollment, eligibility
   determination and benefit distribution (Part C and D
   only)
FUNDAMENTAL ACTIVITIES
 • Matching and analysis of Medicare and Medicaid data
 • Responding to law enforcement requests and
   providing expertise to law enforcement on ongoing
   investigations
 • Implementing appropriate administrative actions
 • Coordinating potential fraud, waste, and abuse
   activities with the appropriate Medicare and
   Medicaid entities and State Agencies
 • Complaint screening (Part C and D only)
FUNDAMENTAL ACTIVITIES

 • Identify Program Vulnerabilities
 • Identify Overpayments
 • Take administrative actions as appropriate
 • Education of providers, beneficiaries, and
   organizations
 • Develop and maintain a data warehouse of claim and
   eligibility data
 • Analysis on advertisement, marketing materials, and
   marketing and sales representative’s behavior trends
TRANSITION
•   Zone 4 – February 1, 2009
•   Zone 7 – February 1, 2009
•   Zone 5 – Not yet announced - overdue
•   Zone 2 – Not yet announced - overdue
•   Zone 1 – Supposed to be March 1, 2009
•   Zone 3 – Not yet released
•   Zone 6 – Not yet released
•   Medi-Medi Task Orders are implemented in various
    orders for each zone depending on state
HIGH RISK AREAS

 High risk areas may be identified by emerging or
   widespread anomalies that may lead to potential
   fraud and abuse in, for example, claim type, provider
   type, and geographic area. This may be demonstrated
   by such situations, including but not limited to:
 • Sudden changes in billing
 • Spike billing
 • Billing by inappropriate specialties
HIGH RISK AREAS
 •   Compromised beneficiary identities
 •   Compromised provider identities
 •   Geographical changes in billing
 •   High CERT rate
 •   Identity Theft (provider and beneficiary)
 •   Beneficiary Recruitment (capping)
HIGH RISK AREAS

 • High, “out of the norm,” UPIN/PIN utilization that
   accounts for a disproportionate share of the
   “ordered” services for a provider or groups of
   providers
 • Billing for claims for deceased patients in which the
   date of services is after the patients’ date of death
 • Billing for Part B services during an inpatient, Part A
   institutional stay
HIGH RISK AREAS
• Billing for ordered services (IDTF, clinical laboratory,
  DME, etc.) in which the ordering physician has no
  billing relationship for the patient (implying lack of
  clinical relationship for the ordering physician and
  beneficiary)
• Billing for deceased physicians or other clinical
  practitioners or billings for “ordered” services based
  upon the UPIN/NPI of a deceased physician or clinical
  practitioner.
HIGH RISK AREAS
• Zone 1
   – Los Angeles, CA
• Zone 3
   – Detroit, MI
• Zone 4
   – Dallas, TX
   – Houston, TX
• Zone 6
   – New York, NY
• Zone 7
   – Miami-Dade, Broward, and Palm Beach counties in the
     State of FL.
WHY IS CMS REVISING THIS
WORKLOAD?
 • To realign with the MAC jurisdictions
 • Results of unfavorable OIG report
    – PSCs had wide range of referral and investigation
      activity
    – 13 of 17 PSCs had few, if any, proactive
      investigations
    – Lack of CMS oversight over PSCs
 • Refocus on pro-active fraud investigations
 • Desire to increase analysis across lines of business
   and Medicaid
HOW WILL YOU BE AFFECTED?

• Increased scrutiny
• Increased focus on proactive data analysis resulting in
  higher number of random audits
• More innovative investigation techniques
• More rapid response to fraudulent practices
• Investigations expanded to include physicians, labs,
  home health agencies, etc
• May review both Medicare and Medicaid claims at the
  same time
HOW WILL YOU BE AFFECTED?
 • More consistent audits over multiple lines of business
 • Increased oversight of government contractors
   performing Program Integrity functions
 • Increased education of providers and beneficiaries on
   fraud and abuse issues
 • Quicker response to fraudulent activity resulting in an
   improved industry image
 • Increased commitment to fighting fraud and abuse
SPECIAL PROJECTS
Infusion Therapy Demonstration Special Study
• Zone 7 - Florida
• Develop and demonstrate improved methods for the
   investigation and prosecution of fraud occurring among
   providers of infusion therapy
• Demonstration Design
    – Provider enrollment and revocations, site visits, data
      analysis and risk assessment
    – Medical Review
    – Customer Service
    – Other administrative actions
    – Evaluation
SPECIAL PROJECTS
 • South Florida and Los Angeles crackdown on DME
   suppliers.
    – 2 year pilot program which requires suppliers to
      reapply for a license after 30 days.
    – If successful, will be expanded nationally.
    – 1,139 suppliers revoked that were paid a
      combined total of $265 million between calendar
      years 2005-2007.
 • Home Health Agency Demo Project in Houston and
   Los Angeles.
    – Similar project as above.
OTHER PROGRAM INTEGRITY EFFORTS
• Recovery Audit Contractors (RACs)
   – Brief explanation or program
   – Name the RACs
• Competitive Bidding
• Accreditation
• Revocations
• Surety Bond
   – $50,000
   – Existing suppliers must comply by October 2, 2009
   – New suppliers must meet this requirement by May 4,
     2009
   – Adverse action may result in a higher surety bond
     requirement on some suppliers
OTHER PROGRAM INTEGRITY EFFORTS
 • Extensive prepayment review of claims submitted by
   ordering / referring MDs
 • Validating claims submitted by MDs who order a high
   number of certain items or services by sending
   follow-up letters to these MDs
 • Verifying the relationship between MDs who order a
   large number of services and the beneficiaries for
   whom they ordered those services
 • Identifying and visiting “high risk” beneficiaries to
   ensure they are appropriately receiving the services
   for which Medicare is being billed.
2009 OIG PRIORITIES
• Pain medication diversions
• Medicare Part D – active beneficiary role in fraud
• DME Equipment
   – Organized crime
   – Identity theft
• “Hit and Run” frauds
• Focus on enrollment
• Medicare and Medicaid investigations
• Support practices of compliance with program requirements
• Services not rendered
• Home Health fraud
2009 OIG WORKPLAN
• DME Payment for beneficiaries receiving Home Health
• Medicare payments for various categories of DME
• Medicare payments for DME claims with modifiers
• Medicare payment for CPAP devices
• CERT Program
   – Determine methodology to determine 2008 DME
     error rate
   – Review DME Corrective Actions to assure CMS
     implements recommendations
• Part B Services in Nursing Homes
   – Enteral Nutrition
2009 OIG WORKPLAN
• Medicare pricing for Enteral Nutrients in nursing homes
  and Parenteral Nutrition
• DME provided to patients in nursing homes
• Medicare Part B payments for diabetic testing supplies
• Duplicate payments to DME suppliers with multiple NPIs
• Payments to suppliers associated with “Currently not
  collectable” overpayments
• Appropriateness of payments for support surfaces
• Comparison of prices for negative pressure wound
  therapy pump
2009 OIG WORKPLAN

•   Medicare payments for power wheelchairs
•   Supplier purchase prices for power wheelchairs
•   Repair and servicing of capped rental DME
•   Appropriateness of DME categorization
WHAT SHOULD I DO?
• Do the right thing!
   – Know the Medicare policies
• Be prepared
   – Consistent orderly files
   – Open communication with referral sources, physicians,
     and beneficiaries
   – If you’re an outlier…know why you are and be
     prepared to explain it
   – Internal compliance programs
   – Employee background checks
   – Random internal audits
     WHAT SHOULD I DO?
Take responsibility for the prevention
    and detection of Medicare and
      Medicaid fraud and abuse.
QUESTIONS
Wayne H. van Halem
Principal, AHFI, CFE
The van Halem Group, LLC
961 Manigault St, SE
Atlanta, GA 30316
404.343.1815 (Office)
404.748.1115 (Fax)
803.238.2684 (cell)
Wayne@vanHalemGroup.com
www.vanHalemGroup.com

								
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