Value-Based Payment Program Integrity (PI): Issues And .

Value-Based Payment Program Integrity (PI):Issues and ConsiderationsPayment IntegrityNovember 16, 2016

2November 16, 2016VBP PI Workgroup AgendaMeeting 1 Data QualityPolicy QuestionDiscussionMeeting 2Policy DesignMeeting 3Payment Integrity Policy QuestionDiscussionDraft & Finalize Consensus Recommendation(s) Finalize Policy Design ConsensusRecommendation(s)Policy Question(s)DiscussionDraft & Finalize Consensus Recommendation(s) Policy QuestionTopics and policy questions were theoutput of the Regulatory ImpactSubcommittee which convened in JulyDecember 2015DiscussionPolicy question frames and providescontext, work subsequent de the State with a consensusrecommendation on each of theworkgroup’s three policy questions

3November 16, 2016AgendaToday’s agenda includes the following:Agenda ItemTimePolicy Design Recap10:30 amFinalize RecommendationsPayment Integrity: Issues and Considerations10:45 am11:30 amThe Changing Landscape of Payment Integrity11:45 pmThe Future of Payment Integrity: Develop PotentialRecommendations12:15 pmConclusion1:30 pm

November 16, 2016Policy Design RecapDetailed findings and finalization of recommendations4

5November 16, 2016Distinguishing Policy Design from Payment IntegrityPolicy DesignPayment IntegrityProspective adjustment to the policy, systems,Fraud, waste, and abuse (FWA) control related toand structures necessary to ensure that providers anti-kickback & Stark laws, inappropriatedeliver high value care to all enrollees.payments, inappropriately limitation of access tocare, default risk reserve, VBP bundle gaming etc.Output: changes to policy, systems andstructures to prospectively avoid undesiredbehavior.Output: identification of FWA activities andsuccessful enforcement actions against violators.The whatThe howHighQualityValueLowCost

November 16, 2016Policy Design: Policy QuestionWhat framework should be put in place to ensure that the transition to VBPdoes not create incentives contrary to the spirit of the program?6

November 16, 2016Draft RecommendationsWhat framework should be put in place to ensure that the transition to VBP does not create incentives contrary to thespirit of the program?1. Define patient access and patient experience measures (i.e. case closures and drops in servicedelivery) for the purposes of evaluating changes in access due to implementation of VBP.2. Implement mandatory reporting of access measures and collection of patient experience measuresto identify potentially inappropriate withholding of services.3. Implement specific oversight efforts targeted at preventing “cherry picking” of populations for whichit is easier to achieve desired cost and outcomes measures.7

November 16, 2016Payment Integrity: Issues andConsiderationsBrief background and context8

9November 16, 2016PI Component #3: Payment IntegrityThe mitigation of undesirableresults that are contrary to theinterests of New York State’sVBP Policy.An introduction of anew payment modelpresents new avenuesfor fraud, waste, andabuse in the Medicaidenvironment.As reimbursementbecomes linked to qualitymeasures, the rightcontrols must be in placeto ensure that qualityreporting is a truereflection of the valuedelivered.

10November 16, 2016Defining Payment IntegrityWithin the context of Program Integrity, Payment Integrity is defined as the control of Fraud,Waste & Abuse.1Fraud1Waste1An intentional deception ormisrepresentation made by aperson with the knowledgethat the deception could resultin some unauthorized benefitto himself or some otherperson.Encompasses theoverutilization orinappropriate utilization ofservices and misuse ofresources, and typically isnot a criminal or intentionalact.Abuse1Provider practices that are inconsistent withsound fiscal, business, or medical practices,and result in unnecessary cost to theMedicaid program, or in reimbursement forservices that are not medically necessary orthat fail to meet professionally recognizedstandards for health care.CMS Health Care Fraud and Program Integrity: An Overview for Providers

November 16, 2016The Medicaid Managed Care Final Rule bolsters PIRequirementsIn May 2016, CMS finalized a sweeping reform that will impact several components of themanaged care programs that New York State (NYS) operates, including PI provisions whichmust be built into NYS’s Model Contract. These reform initiatives include:Fiscal integrity components that enhance rate setting transparency and establish aminimum medical loss ratio (MLR) of 85%Quality improvement efforts that: Promote transparency Encourage stakeholder engagement Align quality measurement and improvement indicators with Marketplace standardsNetwork adequacy requirements that include state developed provider-to-membertime and distance standards11

12November 16, 2016The Medicaid Managed Care Final Rule bolsters PIrequirements (cont.)VBP and delivery system reform efforts that grant states the authority toincentivize and/or compel Medicaid managed care plans to transition to VBPProgram Integrity initiatives that require tri-annual auditing of MCO reportedencounter data (among other requirements)

13November 16, 2016Expanding Managed Care Plans’ Responsibilities InProgram Integrity Efforts1The final rule adds or reinforces several components to strengthenMedicaid and CHIP managed care plans’ program integrity tomonitor, prevent, identify, and respond to suspected fraud:Mandatoryreporting to theMandatoryreporting to thestate of informationreceived by theMandatorystate of informationmanaged care planreporting to thereceived bymanaged careabout changes in astate by managedprovider’scare plans ofplans aboutpotential fraud andchanges in ancircumstances thatimproper paymentsmay affect theenrollee’sidentifiedprovider’scircumstances thatmay affect theparticipation in themanaged careenrollee’s eligibilityprogram1Suspension ofpayments to anetwork providerwhen the statedetermines acredible allegationof fraud exists(§§438.600, 438.602, 438.604, 438.606, 438.608, and 438.610) Pages 110 - 129Establishment andimplementation ofCMS may deferand/or disallow FFPprocedures forinternal monitoring,for expendituresauditing, andunder a MCOprompt response of contract when thepotentialstate’s contract isnon-compliant withcompliance andfraudulently issuesstandardswithin a managedaforementioned.care plan

November 16, 2016The Changing Landscape ofPayment Integrity14

15November 16, 2016The Transformation to VBP: How We Got HereAs delivery moves from FFS, toalternative payment models, the valueof the care delivered becomes anincreasingly important PI concernFee-For-Service— Data analytics and fraud,waste and abuse (FWA)detection— Medicaid population trendsManaged Care— Population shift to capitation— Quality measurements onmanage care organizationpopulations— Encounter data andincreased focus on valueVBP Arrangements— Focus on value over volume

November 16, 2016Program Integrity ProvisionsOMIG conducts and coordinates improper Medicaid paymentrecovery activities OMIG previously shifted resources to match the change in direction awayfrom fee-for-service (FFS) to Medicaid Managed Care (MMC).OMIG has evolved their resources to match the direction ofMedicaid In response to the Medicaid Final rule and the shift to VBP, newprevention efforts will focus on value based payments (VBP).16

17November 16, 2016Potential VBP PI IssuesFraud, Wasteand AbuseIssues

18November 16, 2016Potential VBP PI IssuesWhat CurrentFWA IssuesChange in VBP?Fraud, Wasteand AbuseIssuesWhat FWA Issuesare New becauseof VBP?How is FWAMeasured inVBP?

19November 16, 2016Potential VBP PI IssuesAnti-Kickback& Stark*What CurrentFWA IssuesChange in VBP?FraudulentPaymentsDefault RiskReserveFraud, Wasteand AbuseIssuesWhat FWA Issuesare New becauseof VBP?How is FWAMeasured inVBP?* Relevant recommendations generated by Regulatory Impact Subcommittee

20November 16, 2016Potential VBP PI IssuesAnti-Kickback& Stark*What CurrentFWA IssuesChange in VBP?FraudulentPaymentsDefault RiskReserveFraud, Wasteand AbuseIssuesWhat FWA Issuesare New becauseof VBP?How is FWAMeasured inVBP?* Relevant recommendations generated by Regulatory Impact SubcommitteeVBP-SpecificInappropriateBehavior

21November 16, 2016Potential VBP PI IssuesAnti-Kickback& Stark*What CurrentFWA IssuesChange in VBP?FraudulentPaymentsDefault RiskReserveFraud, Wasteand AbuseIssuesWhat FWA Issuesare New becauseof How is FWAMeasured inVBP?* Relevant recommendations generated by Regulatory Impact SubcommitteeOther Data

22November 16, 2016Payment Integrity ImplicationsFW&A: OverlappingArrangementsA.B.C.IPC or Total CareGeneralPopulationMaternity CareHIV/AIDSPI Implication:Incentive for ‘upcoding’and for cost-shifting toincrease the changes forshared savings (orreduce changes forlosses)FW&A: Stop Loss GamingA.B.Disproportionatelyexpensive patientsExceeding the stoploss threshold.PI Implication:New avenues of fraudexist for providers whointend to game a stoploss arrangement.Policy: Limiting Access toCareA.B.Fee-for-Service(FFS): Paymentbased on volume.Fully CapitatedArrangement: PerMember PerMonth (PMPM)paymentPI Implication:The physician limitsoffice hours, limitingaccess to care.Data: Comparing Encountersto Lab ResultsA) Program EnhancerPI Implication:A Policy Director couldcompare lab results toencounters to determine ifthere exits evidence ofupcoding.

November 16, 2016The Future of PaymentIntegrityDevelop Potential Recommendations23

November 16, 2016Payment Integrity : Policy QuestionWhat Program Integrity infrastructure needs to be changed in order toestablish a solid foundation for Medicaid payment integrity as it relates toVBP implementation in NYS?A. What are the broad Program Integrity issues that manifest themselves through VBP with regard topartner agencies? What changes need to be made in response to these issues?i. Office of the Medicaid Inspector General (OMIG)ii. Office of Mental Health (OMH)iii. Office of Health Insurance Programs (OHIP)iv. Office of Quality and Patient Safety (OQPS)v. Office for People with Developmental Disabilities (OPWDD)vi. Office of Alcoholism and Substance Abuse Services (OASAS)vii. Other Agencies of Concern24

November 16, 2016Payment Integrity: Policy QuestionWhat Program Integrity infrastructure needs to be put into place thatestablishes a solid foundation for Medicaid payment integrity as it relates toVBP implementation in NYS?B. Where should accountabilities for payment integrity responsibilities lie in relation to MedicaidProgram Integrity?i. How will OMIG, OHIP, and other stakeholders redefine their agency roles and support eachother’s distinct efforts to control FW&A?ii. With the shift to VBP, what are the priority areas of focus within NYS Medicaid ProgramIntegrity, and how will this be communicated to stakeholders?iii. Other25

November 16, 2016Payment Integrity: Policy Question (cont.)What Program Integrity infrastructure needs to be put into place thatestablishes a solid foundation for Medicaid payment integrity as it relates toVBP implementation in NYS?C. How can NYS determine whether the existing policies, laws, and regulations are adequate toallocate responsibility for payment integrity enforcement among stakeholders?i. Should the Department perform a contractual and functional assessment to determinealignment with the MCO Final Rule?i. Are the appropriate resources, infrastructure, and protocols in place to support necessaryfuture state payment integrity?ii. Should a written protocol be developed wherein safeguards are developed and issued in amanner which can be legally enforced and where either the OMIG and/or DOH identifies highlikelihood targets for enforcement actions?26

27November 16, 2016Thank You!

Contact Us:Jeffrey GoldCo-Chairjgold@hanys.orgRobert HussarCo-Chairrhussar@barclaydamon.comJonathan BickDOH SponsorJonathan.bick@health.ny.gov

Nov 16, 2016 · Defining Payment Integrity Within the context of Program Integrity, Payment Integrity is defined as the control of Fraud, Waste & Abuse. 1 CMS Health Care Fraud and Program Integrity: An Overview for Providers Fraud1 Waste 1Abuse An intentional deception or misrepresentation made by a