Presentation Before The MO HealthNet Oversight Committee June 7, 2011 .

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Presentation Before the MO HealthNet Oversight CommitteeJune 7, 2011Markus P. Cicka, J.D., L.L.M. (Health Law)Director – Missouri Medicaid Audit and ComplianceMissouri Department of Social Services205 Jefferson St., 2nd Floor, P.O. Box 6500Jefferson City, MO 65102-6500(573) 751-3399 (Telephone)(573) 526-4375 (Fax)

Embedded in Medicaid In December, 2009, Program Integrity was located within theMO HealthNet Division of Missouri's Department of SocialServices. Also at that time, Missouri Medicaid dollars were flowing into,and being disbursed by, three entities within Missouri's Stategovernment: the Missouri Department of Social Services; the Missouri Department of Health and Senior Services;and the Missouri Department of Mental Health. In addition, the Provider Enrollment Unit was locatedwithin the Missouri Department of Social Services, MOHealthNet Division.Markus P. Cicka, J.D., L.L.M. (Health Law)2

MO HealthNet Division in December, 2009DirectorDeputy Division DirectorOperationsMarkus CickaDirectorProgram IntegrityandCost ManagementDeputy Division DirectorClinical ServicesChief Financial OfficerFinanceMedical ConsultantFiscal & Administrative Mgr.Office ServicesDirector of PharmacyDirector of FinanceFinanceDirector of ClinicalFiscal & Administrative Mgr.BudgetMarkus P. Cicka, J.D., L.L.M. (Health Law)3

INDEPENDENTPLACEMENTMarkus P. Cicka, J.D., L.L.M. (Health Law)4

Organizational Structure of MissouriMedicaid Audit and Compliance TodayState of MissouriRevenueChildren’sServicesDepartment ofSocial ServicesMO HealthNetDivisionOffice ofAdministrationMMACMarkus P. Cicka, J.D., L.L.M. (Health Law) 12 Others 3 Others5

Missouri Medicaid Audit and Compliance inJanuary, 2011Markus CickaDirector- Missouri MedicaidAudit and ComplianceProvider Review& Lock-InProviderReviewInvestigations igationsHCBS ProviderEnrollment &ReviewMarkus P. Cicka, J.D., L.L.M. (Health Law)ProviderEnrollmentProviderManualAudit6

DirectorManagementAnalyst II,FADSAdministrative OfficeSsupportAssistantDeputy Director,Program IntegrityLegal CounselDeputy Director,Investigation,EnrollmentSenior OfficeSupportAssistantSenior OSfficeSupportAssistantFiscal and AdminMGR B1, Fiscal,Racs, Acct RecRN IVRN IIIMedicaid UnitSupervisor,ADHC, DHSS,Med SpecialistMedicaid UnitSupervisor,DMHMed SpecialistMedicaid UnitSupervisorMed SpecialistMed SpecialistMed SpecialistCorrespondenceand tant IMedicaidClerkEnrollmentMed SpecialistRACMedicaidClerkEnrollmentAcct Clerk IIMed SpecialistMed SpecialistMed SpecialistMedSpecialist,PERMMed SpecialistAuditor III,Internal AuditDirect reportto DeputyMed SpecialistContractsAuditor IAuditor IInvesitgator IIMedicaidClerk,EnrollmentMed Specialist,ContractsInvestigator tMed tractsMedicaidClerkEnrollmentSenior OfficeSupport AssistantAuditor IAuditor IInvesitgator IIInvestigator IIMed SpecialistMedicaidTech(pharmacy)Medicaid UnitSupervisor,Contracts &TerminationsAuditor ICorrespondeceand informationSpecialistMed SpecialistRegisteredNurse II,Office SupportAssistantOffice SupportAssistantMed SpecialistRN IIMedicaidUnitSupervisor,EnrollmentMed SpecialistMed SpecialistAuditor IIMedicaidClerkEnrollmentMed SpecialistMed SpecialistMed SpecMed SpecialistMed SpecialistMed SpecialistMedicaidTechnicianSenior OfficeSupportAssistantMgt Anal SpecII, DHSSfinancialsInvestigator IIInvestigator IISenior OfficeSupportAssistantMed SpecialistMedicaidTechnicianMarkus P. Cicka, J.D., L.L.M. (Health Law)7

Missouri Medicaid Audit andCompliance UnitThe Missouri Medicaid Audit and Compliance Unit (MMAC)is responsible for the oversight and the auditing of compliance ofthe Missouri Medicaid providers and participants. TheMMAC is charged with the responsibility of detecting,investigating, and preventing fraud, waste and abuse of theMissouri Medicaid Title XIX Program.Markus P. Cicka, J.D., L.L.M. (Health Law)8

MMAC is divided into four major organizational components: Administration Section Financial Section Provider Review and Lock-In Section; and Investigations and Provider Enrollment Section.Markus P. Cicka, J.D., L.L.M. (Health Law)9

Financial Section The Financial Section has charge of the Recovery AuditContractor (RAC) program and internal compliance withoutside assessment review of the Missouri Medicaid TitleXIX Program. The state of Missouri has two annual reviews of the TitleXIX Program responsibility for which is charged to theFinancial Services Section. This section is also tasked with auditing managed careorganizations and other providers and developingMedicaid fraud and abuse standards for managed careorganizations.Markus P. Cicka, J.D., L.L.M. (Health Law)10

Provider Review & Lock-In SectionProvider Review Group The Provider Review Group is responsible for reviewing andmonitoring statewide utilization and program compliance ofMedicaid fee-for-service providers. The Group conducts post-payment reviews and researchescomplaints. Following a review, the Group may issue providersanctions in accordance with applicable federal and state lawsand regulations, including, but not limited to, educationalletters, recovery of improperly paid funds, and request for acorrective action plan. The Group is responsible for detecting and identifying patternsof provider fraud, reviewing provider records, claims andpayments to determine whether fraud, waste and abuse exists.Markus P. Cicka, J.D., L.L.M. (Health Law)11

Provider Review Group (cont’) The Group is responsible for referring suspected fraud cases tothe MMAC Investigations Group for further and fullinvestigations.Markus P. Cicka, J.D., L.L.M. (Health Law)12

Provider Review Group (cont’)Claims processingUpon a provider submitting a claim electronically, the claim goesthrough a series of edits, including: Data validity Participant eligibility and third party liability Provider eligibility and pricing History checking including medical criteria Prior authorization Certification Pre-payment review (medical consultant review)Markus P. Cicka, J.D., L.L.M. (Health Law)13

Provider Review Group (cont’)Post-Payment Review Providers are selected to be reviewed from either referral,exception reports, and/or other system generated reports. Referrals concerning possible misutilization may be receivedfrom providers, participants, consultants, employees, and stafffrom other agencies. Exception reports are produced on providers that haveexceptional patterns of utilization, or that deviate fromestablished norms.Markus P. Cicka, J.D., L.L.M. (Health Law)14

Provider Review Group (cont’) A review of claims reimbursed is performed on each of theselected providers or project in order to determine programcompliance. This review is completed by either desk review or field review. The appropriateness and quality of service are also consideredfor the claims being reviewed. If a question regarding thequality of service, medical necessity or medical interpretationexists, the case is referred to the Division’s State Consultantsfor review.Markus P. Cicka, J.D., L.L.M. (Health Law)15

Provider Review Group (cont’)Sanctions/Administrative ActionsThe outcome of a provider review may include one more of thefollowing administrative actions: Determination of overpayment. If an overpayment is identified, a certified mailing is sent tothe provider outlining all errors noted in the review andinforming the provider of the total amount overpaid. The provider is also notified of any repayment optionsavailable to them. Withholding of payments. Transfer to closed-end agreement. Provider education.Markus P. Cicka, J.D., L.L.M. (Health Law)16

Provider Review Group (cont’)Sanctions/Administrative Actions Pre-payment review. A means by which a provider’s claims are reviewed by theState Consultant prior to payment to determinereasonableness and appropriateness of services andcharges. The Consultant monitors all claims submitted bythe provider for services rendered to MO HealthNet-eligibleparticipants and payment is denied for all incorrectly billedservices. Referral to another State agency Suspension TerminationMarkus P. Cicka, J.D., L.L.M. (Health Law)17

Provider Review Group (cont’)Sanctions/Administrative Actions Referrals If the review findings question the provider’s license orcertification, an appropriate referral is made to ProfessionalRegistration. If the review findings question the provider’s Bureau of Narcoticand Dangerous Drugs prescribing privileges, the appropriatereferral is made to the Bureau. If a question of potential fraud exists, the case is referred to theOffice of the Attorney General-Medicaid Fraud Control Unit. PI staff also review and monitor the utilization of participants. Ifparticipants are found to abuse a program, such as emergencyroom visits for non-emergency situations, the staff will lock theparticipant into a specific provider and monitor the utilizationvery closely.Markus P. Cicka, J.D., L.L.M. (Health Law)18

Participant Lock-In Group The Participant Lock-In Group is responsible for reviewing andmonitoring statewide utilization and program compliance ofMedicaid fee-for-services participants. The Group conducts reviews of participant activity regardingthe number of physicians and pharmacies visited to determinewhether the probability of fraud, waste and abuse exits. The Group is responsible for referring suspected participantfraud cases to the MMAC Investigations Group for further andfull investigation.Markus P. Cicka, J.D., L.L.M. (Health Law)19

Participant Lock-In Group (cont’) The Group is responsible for monitoring participants whoare participating in fraud, waste and abuse of theMedicaid Title XIX program by mandating that suchparticipants receive Medicaid services through certainproviders or pharmacies and ensuring those participantsutilize their Medicaid benefits with only those providersor pharmacies.Markus P. Cicka, J.D., L.L.M. (Health Law)20

Investigations & Provider EnrollmentSection The Investigations and Provider Enrollment Section is dividedinto the following groups: Investigations Group; Provider Enrollment Group; Home and Community Based Provider Enrollment andReview Group; and Provider Manual Audits GroupMarkus P. Cicka, J.D., L.L.M. (Health Law)21

Investigations Group The Investigations Group is responsible for receiving and fullyinvestigating allegations of Missouri Medicaid Title XIXprogram fraud against both providers and participants frommultiple sources. The Group provides assistance to other state Departmentsand/or Divisions to detect fraud, waste and abuse of theMissouri Medicaid Title XIX Program. After conducting a thorough investigation, including obtainingand reviewing provider and medical records, interviewingproviders, participants, and any other applicable individuals,and obtaining and reviewing any other records, document,and information deemed necessary to complete a fullinvestigation, the Group is responsible for determiningwhether referrals to any appropriate law enforcementagencies are warranted.Markus P. Cicka, J.D., L.L.M. (Health Law)22

Investigations Group (cont’) The law enforcement agencies may include, but are notlimited to, local law enforcement agencies, the Medicaid FraudControl Unit (MFCU) within the Missouri Office of AttorneyGeneral, and the FBI.Markus P. Cicka, J.D., L.L.M. (Health Law)23

Provider Enrollment Group The Provider Enrollment Group is responsible for reviewingapplications for Medicaid Title XIX providers. The applications may include, but are not limited to, newprovider applications, re-enrolling provider applications,revalidation provider applications, and change of ownershipprovider applications. The Group screens all provider applications to determinewhether there exists a history of provider sanctions, fraud,previous professional licensing sanctions or terminations,previous termination as a Medicare or Medicaid provider, andwhether the provider is in compliance with federal and statelaws and regulations required to become a Medicaid Title XIXprovider.Markus P. Cicka, J.D., L.L.M. (Health Law)24

Provider Enrollment Group (cont’) The Group is responsible for determining whether to accept ordeny a provider application pursuant to applicable federal andstate laws and regulations The Group maintains updates and changes to the providerenrollment files and processes the direct deposit applicationfees and application fee hardship waiver requests. The Group responds to provider inquiries and notifiesproviders when their application is processed and when aprovider number is issued.Markus P. Cicka, J.D., L.L.M. (Health Law)25

Home & Community Based ProviderEnrollment and Review Group The Home and Community Based Provider Enrollment andReview Group is responsible for reviewing applications forMedicaid Title XIX Home and Community Based Providersproviding services to the Department of Health and SeniorServices’ clients. The applications may include, but are not limited to newprovider applications to determine whether there exits ahistory of provider sanctions, fraud, previous terminations as aDepartment of Health and Senior Services, Medicare, orMedicaid provider, and whether the provider is in compliancewith federal and state laws and regulations required tobecome a Medicaid Title XIX provider.Markus P. Cicka, J.D., L.L.M. (Health Law)26

Home & Community Based ProviderEnrollment and Review Group (cont’) The Group is responsible for determining whether to accept ordeny a provider application based on the information availableand pursuant to applicable federal and state laws andregulations. The Group maintains updates and changes to the providerenrollment files and processes the direct deposit applications,the application fees and application fee hardship waiverrequests. The Group responds to provider inquiries and notifiesproviders when their application is processed and when aprovider number is issued.Markus P. Cicka, J.D., L.L.M. (Health Law)27

Home & Community Based ProviderEnrollment and Review Group (Cont’) The Group may also conduct on-site and desk reviews ofproviders as deemed necessary to ensure providers are incompliance with federal and state laws and regulations. The Group will issue sanctions as deemed necessary.Markus P. Cicka, J.D., L.L.M. (Health Law)28

Provider Manual Audits Group The Provider Manual Audits Group is responsible forperforming reviews of provider manuals to ensure themanuals accurately incorporate necessary changes related topolicy and federal and state laws and regulations. The Group works with the Department of Social Services, theDepartment of Health and Senior Services, and theDepartment of Mental Health to ensure the propermaintenance of manuals that regulate the management of theMissouri Medicaid Title XIX program.Markus P. Cicka, J.D., L.L.M. (Health Law)29

Implications to Program integrity Effortsof Organizational Location Decrease lag time in updating and implementing MMIS edits Increased combined Program Integrity and Provider Enrollment staff from approximately 35 to approximately 80.Staff includes more analysts, investigators, internal auditors andhome/community based contract reviewersInvestigators now utilized to investigate provider and participantfraudOn-site audits becoming more routine and prevalentProvider Enrollment fully integrated into MMACMarkus P. Cicka, J.D., L.L.M. (Health Law)30

Provider Enrollment now focused on compliance with federalregulations regarding screenings, terminations and exclusions Moving toward re-enrolling/re-validating providers on a cyclicalbasis Internal auditors ensure update of policy, procedures andregulations by all departments receiving Medicaid funds. Increasedefforts to identify fraudulent providers and participants whilecontinuing efforts at reducing unintentional billing errors. Enhanced ability to carry-out audit and compliance of other stateorganizations serving Medicaid recipients Markus P. Cicka, J.D., L.L.M. (Health Law)31

THANK YOUMarkus P. Cicka, J.D., L.L.M. (Health Law)32

Also at that time, Missouri Medicaid dollars were flowing into, and being disbursed by, three entities within Missouri's State government: the Missouri Department of Social Services; the Missouri Department of Health and Senior Services; and the Missouri Department of Mental Health. In addition, the Provider Enrollment Unit was located

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