NYS Medicaid Inspector General Releases 2015-16 Work Plan

The New York State Office of the Medicaid Inspector General (OMIG) released its 2015-16 Work Plan. The Work Plan spells out the OMIG’s activities and priorities for the fiscal year commencing April 1. OMIG audits tend to focus on the issues set forth in the Work Plan.

The Work Plan highlights the creation of two new Business Line Teams (BLTs), one focusing on reviews related to the Delivery System Reform Incentive Payment (DSRIP) Program and one focusing on Managed Long Term Care (MLTC) plans. BLTs are multi-disciplinary teams that take the lead on audits and activities concerning specified categories of Medicaid services. The following is an overview of the planned areas of focus for the BLTs most relevant to LeadingAge New York members. The complete Work Plan can be found here.

DSRIP

The DSRIP BLT will engage in the following activities in relation to DSRIP Performing Provider Systems (PPSs):

Review network attestation forms submitted by PPS leads and provide results to the Department of Health (DOH) for consideration in connection with DSRIP applications.
Provide guidance to PPS leads on mandatory compliance obligations, including risk areas associated with the organizational structure and functions of PPSs.
Conduct compliance program reviews of PPS leads to determine whether they have satisfied mandatory compliance obligations.

Home Health

The Home Health BLT covers Certified Home Health Agencies (CHHAs) personal care providers, Long Term Home Health Care Programs (LTHHCPs), traumatic brain injury waiver services and private duty nursing services. It will engage in the following activities in relation to these providers:

Analyze claims to determine whether appropriate supervision was provided; the staff was properly qualified, licensed and trained; and other personnel requirements were met.
Analyze claims to determine whether an approved patient care plan exists, plan services were deemed necessary, services were rendered consistent with the patient care plan and hours billed were authorized by the care plan.
Determine whether spend-down amounts are processed correctly when the respective county assigns responsibility for monitoring the spend-down to the provider.
Identify home health and personal care providers who bill while the consumer is in a hospital or in an institutional setting, where the billed services are covered by the facility rate.
Identify overlapping payments for consumers who are dually eligible for Medicare and Medicaid and are receiving home health services, to ensure that Medicaid is the payer of last resort.
Ensure that CHHAs, LTHHCPs and Personal Care providers that receive total Medicaid reimbursements exceeding $15 million annually, through Fee-For-Service (FFS) or managed care, retain a verification organization that implements automated controls to verify services provided, arrival time, departure time and aide identity for home care services.
Review LTHHCP and CHHA cost reports to verify per-visit and hourly rates calculated for the various ancillary services provided, with an emphasis on both high Medicaid utilization and rate capitations. OMIG will also review rate add-ons, including funds dedicated to worker recruitment, training, and retention.
Working with a contractor, the University of Massachusetts Medical School, pursue reimbursement from Medicare for home health services delivered to dual eligible beneficiaries and paid for by Medicaid.

Managed Care

The managed care BLT will focus on the following:

Review FFS payments for services rendered to managed care enrollees to determine whether the services were included in the managed care benefit package.
Examine claims with a date of service after the date of death of the member or during a period of incarceration or institutionalization.
Review various aspects of the cost reports and the underlying data to identify whether un-allowed costs are included.
Use encounter data as the operational base, instead of FFS paid claims data, to support collection of third party liability revenue.
Review managed care edits that validate encounter records, and work with MCOs to strengthen systems controls and share best practice edits.
Review Medicaid payments for members with multiple client identification numbers.
Provide contractual, administrative, and medical utilization review oversight of MCOs’ Recipient Restriction Programs (RRPs) to enhance MCOs' adherence to federal and State regulations and monitor program outcomes. OMIG will share restriction information with MCOs to permit restrictions to follow the member regardless of plan membership.
Determine whether MCOs are returning monthly capitation payments when members are retroactively disenrolled.
Work with MCO Special Investigative Units (SIUs) to support the exchange of fraud and abuse allegation information among SIUs, coordinate responses to identified targets, review the quarterly/biannual/annual reports from the MCOs, and “act as a coordination and de-confliction center” for internal and external investigations of fraud and abuse.

Managed Long Term Care

The MLTC BLT will focus on the following issues and activities:

Review enrollment records to determine whether the MLTC plans properly determined eligibility for enrollment and provided proper care management to selected members.
Investigate Social Adult Day Care Centers (SADCs), including joint investigations with the Medicaid Fraud Control Unit and the New York City Buildings Department, when possible. In addition, OMIG will work with the State Department of Health and State Office for the Aging to “improve system controls over SADC.”

Residential Health Care Facilities (i.e., Nursing Homes and Assisted Living Programs (ALPs))

A single BLT, entitled the Residential Health Care Facility BLT, covers both nursing homes and ALPs. This BLT will conduct the following activities in relation to ALPs in the coming year:

Review documentation of care given to ALP residents, focusing on timely medical evaluations, interim assessments, plans of care, functional assessments and the presence of relevant evidence of service provision. OMIG will oversee ALP resident care reviews conducted by County Demonstration program participants. OMIG will also provide oversight of ALP rate reviews that are conducted by County Demonstration program participants.
Identify goods and services delivered to ALP residents by other providers and billed to the Medicaid program, which were also included in the ALP payment rates.

The Residential Health Care Facility (RHCF) BLT will engage in the following activities in relation to nursing homes:

Review new base year rates approved by DOH for nursing homes focusing on inappropriate and unallowable costs included in the new RHCF rates. OMIG will also “review add-ons to determine whether they were appropriately calculated.”
Review nursing homes’ bed hold payments to determine whether the facilities were eligible to receive them.
Audit underlying costs included in the capital component of nursing home rates, and if necessary, make appropriate adjustments to the rates.
Match nursing home resident Part B data with the Centers for Medicare and Medicaid Services and conduct risk assessments and reviews of the Part B Offset for facilities that are rated as high risk. Review any Part B offset appeals processed by DOH.
Collaborate with DOH to assess the accuracy of MDS data submissions impacting July 1, 2014 through June 30, 2015 Medicaid nursing home rates.
Carry forward base year operating cost audit findings and adjust rates accordingly based on the trend factor.
Review rate appeals that have been approved by DOH and, where indicated, audit underlying costs associated with those appeals.

Hospital and Outpatient Services: Non-Emergency Services to Non-Residents

One area of focus of the Hospital and Outpatient BLT may impact long term care providers. This BLT “will review hospital emergency services provided to non-U.S. residents that lead to inpatient temporary and long-term care stays that do not comply with State and federal regulations.” It will examine documentation of both the emergency room visit and any subsequent paid claims for hospital or long-term care services.

Other Activities

In addition to the issues and activities that relate to individual business lines, the OMIG will be engaged in a variety of activities that cut accross business lines, including the following:

County Demonstration Program: OMIG will continue working with county social service districts and the New York City Human Resource Administration (HRA) to conduct reviews in the areas of pharmacy, transportation, durable medical equipment and assisted living.
Medicaid Integrity Contractor Audits: CMS has contracted with IPRO to conduct MIC audits throughout the State.
Medicaid Recovery Audit Contractor: The RAC will conduct credit balance reviews and payment integrity reviews. It will identify overpayments in hospital and long-term care settings through both onsite and desk reviews. RAC Payment Integrity reviews will cover a variety of projects derived from data mining activities, reports by other audit agencies and issues identified by providers and field office staff.
Prepayment Review: OMIG will assess claims submitted by providers before payment is made. Areas of focus will include home care agencies’ transportation billing, dentists, DME claims submitted with no diagnostic code, misuse of National Provider Identifiers as a prescribing, referring, or servicing provider, pharmacy and private-duty nurses.
Medicare Coordination of Benefits with Provider-Submitted Claims. OMIG will monitor the Medicare/Medicaid claim crossover process and identify inaccuracies in payment information. OMIG will also coordinate with DOH to identify and correct linked providers with different entity identification numbers.
Medi-Medi project: OMIG is collaborating with SafeGuard Services (SGS) in this joint federal-State program to perform coordinated investigations and prepayment reviews of providers with suspicious billing patterns. The providers are identified through CMS’s Fraud Prevention System (FPS) using predictive modeling.
Third-Party Liability and Commercial Direct Billing: OMIG will work with third-party insurance carriers to ensure that retroactive claims processing is conducted in accordance with State and federal law.
Fee-for-Service Third-Party Retroactive Recovery Projects: An updated third-party file will be matched against the eMedNY claims extract file to identify claims for which potential or verifiable third-party liability exists.
Prepayment Insurance Verification: OMIG will identify third-party coverage of Medicaid beneficiaries and update the third-party file on eMedNY prior to payments being made by Medicaid.
Undercover operations: Undercover operations will be used to uncover quality-of-care issues, billing problems and systemic fraud, and to gather intelligence.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383