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Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services
CMS PROGRAM INTEGRITY EFFORTS
2003
Centers for Medicare & Medicaid ServicesCenters for Medicare & Medicaid Services
CMS PROGRAM INTEGRITY EFFORTS
2003
Jim BryantCMS, Boston Regional OfficeDivision of Financial Management
By:
Upcoming CMS Program Integrity Changes
Upcoming CMS Program Integrity Changes
Increasing Focus on Medical ReviewIncreasing Focus on Medical ReviewHiring more clinical staffHiring more clinical staff
Increased outreach to providersIncreased outreach to providers
Increased use of data analysis to tailor program integrity Increased use of data analysis to tailor program integrity effortsefforts
Open Door Forum ScheduleOpen Door Forum Schedule
Open Door Forum NewsletterOpen Door Forum Newsletter
Open Door Forum Chairs/Co-ChairsOpen Door Forum Chairs/Co-Chairs
Deputy Regional Adm instratorW ilm a C ooper, Acting
M a na g em en t A ss ista n t - Lu c ia L a ng e rm an6 1 7-5 65 -11 85
Beneficiary & ProviderServices Branch
Branch Chief: M arva Natha n617-565-123 2
M edicare M anaged CareBranch
Branch Chief: T hom as M into n617-565-126 7
D ivisio n of M edicareO p era tio ns
A s so cia te R e g ion a l A dm in istra to rA v a C hu ng , 61 7-5 65 -12 33
Financial Managem entBranch
Branch Chief: Herve G uerette617-565-125 1
Program IntegrityBranch
Acting B ranch Ch ief: Patric ia G alv in617-565-133 4
D ivisio n of M edicare F in an c ialM anag em ent
A s so cia te R e g ion a l A dm in istra to rJa m e s B rya n t, 61 7 -56 5 -1 3 22
Financial M anagemtBranch
B ranch Chief: R ichard M cG rea l(617-565-1 226 )
M edicaid ProgramBranch
Branch Ch ief: M arg aret Leon i617-565-129 9
D ivisio n of M edica idan d C h ild ren 's Hea lth
A s so cia te R e g ion a l A dm in istra to rB ru ce D . G re e ns te in , 6 17 -56 5 -1 2 23
Clinical S tandardsand Q uality Branch
Branch Chief: Doris W es t(617 )565 -132 0
D ivis io n o f Q u a lityIm p ro vem ent
A s so cia te R e g ion a l A dm in istra to rD r. W illia m Ta ylo r, 61 7 -5 65 -1 3 20
Boston Regional Adm inistratorDr. Charlo tte Yeh
S e c re ta ry - N o ra M o rris6 1 7-5 65 -11 88
Department of Health and Human Services
Centers for Medicare & Medicaid Services (CMS)
Boston Regional Office
(As of June 8, 2003)
Regional Office ContactsRegional Office Contacts
Jim Bryant, ARA for Medicare Financial Management Jim Bryant, ARA for Medicare Financial Management
617.565.1331 [email protected] [email protected]
Reimbursement/Cost Report Lead - Jim MenzaReimbursement/Cost Report Lead - Jim Menza
617.565.1278 [email protected] [email protected]
OPPS - Marcia WidmerOPPS - Marcia Widmer
617.565.1219 [email protected] [email protected]
LTC PPS - Diana GiacaloneLTC PPS - Diana Giacalone
617.565.1205 [email protected] [email protected]
Psych PPS - Gil Mason Psych PPS - Gil Mason
617.565.1238 [email protected] [email protected]
Progressive Corrective ActionProgressive Corrective Action
To identify and target problem providers To identify and target problem providers
Hallmarks:Hallmarks: all decisions are data drivenall decisions are data driven
emphasis on educationemphasis on education
allow for varying review levelsallow for varying review levels
Progressive Corrective Action(continued)
Progressive Corrective Action(continued)
Determining Appropriate ActionsDetermining Appropriate Actions Primary ConsiderationPrimary Consideration
Error Rate CalculationError Rate Calculation
Secondary ConsiderationsSecondary Considerations Mitigating CircumstancesMitigating Circumstances
Aggravating CircumstancesAggravating Circumstances
Review Level Increases as Level of Concern Review Level Increases as Level of Concern IncreasesIncreases
Progressive Corrective Action(continued)
Progressive Corrective Action(continued)
Mitigating CircumstancesMitigating Circumstances Favorable Self AuditsFavorable Self Audits
Voluntary DisclosuresVoluntary Disclosures
Voluntary Compliance PlanVoluntary Compliance Plan
Favorable Appeals DecisionsFavorable Appeals Decisions
Progressive Corrective Action(continued)
Progressive Corrective Action(continued)
Aggravating CircumstancesAggravating Circumstances High percentage of claims with errorsHigh percentage of claims with errors
History of prior billing problemsHistory of prior billing problems
Adverse findings from other reviewsAdverse findings from other reviews
Significant number of beneficiary complaintsSignificant number of beneficiary complaints
Payment ErrorsPayment ErrorsPayment ErrorsPayment Errors
YearEstimated Erroneous
PaymentsError Rate as % of Medicare
Spending1996 $23.2 Billion 14%1997 $20.3 Billion 11%1998 $12.6 Billion 7.1%1999 $13.5 Billion 7.97%2000 $11.9 Billion 6.8%2001 $12.1 Billion 6.3%2002 $13.3 Billion 6.3%
Comprehensive Error Rate Comprehensive Error Rate Testing (CERT) ProgramTesting (CERT) Program
Comprehensive Error Rate Comprehensive Error Rate Testing (CERT) ProgramTesting (CERT) Program
CMS has entered into a contract with CMS has entered into a contract with AdvanceMed under its MIP contracting AdvanceMed under its MIP contracting authority.authority.
The purpose of the contract is to:The purpose of the contract is to: produce a national contractor specific and produce a national contractor specific and
benefit category specific paid claim error ratebenefit category specific paid claim error rate
CERT Program (cont.)CERT Program (cont.)
Independent reviewers will review Independent reviewers will review statistically valid samples of claims as they statistically valid samples of claims as they are processedare processed
Results:Results: National paid claims error rateNational paid claims error rate
Error rate for Medicare contractors nationwideError rate for Medicare contractors nationwide
Estimated Improper Payments by Type of Error (Dollars in Billions)
$4.3 $5.5
$2.1
$9 $10.8
$5.1 $4.4
$7
$7.5
$8.5
$1.7 $2.1 $2.3
$3
$2
$0.7 $1.5
$1.2
$0.8
$1.8
$0.00
$5.00
$10.00
$15.00
$20.00
$25.00
FY 1996 FY 1997 FY 1998 FY 1999 FY 2000
Noncovered Services/Other
Coding Errors
Medically Unnecessary Services
Unsupported Services
$23.2 billion (14%)
$20.3 billion (11%)
$12.6 billion (7.1%)$13.5 billion (7.97%)
$11.9 billion 6.8%)
ContractorsContractors
Anthem Health Services Anthem Health Services (Vt/NH)(Vt/NH)
Rhode Island Blue Cross (to Rhode Island Blue Cross (to be replaced)be replaced)
Empire (Ct.)Empire (Ct.)
Associated Hospital Services Associated Hospital Services (Ma/Me) (Ma/Me)
First Coast (Ct)First Coast (Ct)
Rhode Island Blue Shield Rhode Island Blue Shield (to be replaced)(to be replaced)
National Heritage Insurance National Heritage Insurance Company (Ma/Me/NH/Vt)Company (Ma/Me/NH/Vt)
Part A - Fiscal IntermediariesPart A - Fiscal Intermediaries Part B - CarriersPart B - Carriers
Upcoming CMS ChangesUpcoming CMS ChangesUpcoming CMS ChangesUpcoming CMS Changes
Hiring Special Program Integrity ContractorsHiring Special Program Integrity Contractors Region A DMERC Region A DMERC
Benefit Integrity Support CenterBenefit Integrity Support Center
Coordination of Benefits ContractorCoordination of Benefits Contractor
CERT ContractorCERT Contractor
Benefit Integrity Support CenterBenefit Integrity Support Center
Provision of Data Analysis Support to Fiscal Provision of Data Analysis Support to Fiscal Intermediaries Servicing New England BeneficiariesIntermediaries Servicing New England Beneficiaries
Creation of Data Warehouse for all Part A, Part B Creation of Data Warehouse for all Part A, Part B and DME data for New England Beneficiariesand DME data for New England Beneficiaries Access to Data Base available to CMS RO, all New Access to Data Base available to CMS RO, all New
England Medicare Contractors, OIGEngland Medicare Contractors, OIG
Region A DMERCRegion A DMERC
Responsible for Fraud and Medical Review functions Responsible for Fraud and Medical Review functions of DME claims for Region A (the Northeast)of DME claims for Region A (the Northeast) Will increase data analysis capabilities Will increase data analysis capabilities
Coordination of Benefits Contractor
Coordination of Benefits Contractor
CMS hired GHI as a contractor to identify health CMS hired GHI as a contractor to identify health insurance coverage of Medicare beneficiaries and to insurance coverage of Medicare beneficiaries and to coordinate the payment process centrally.coordinate the payment process centrally.
GHI investigates coverage and maintains a data base GHI investigates coverage and maintains a data base on thison this
GHI then assigns contractors as “leads” to respond to GHI then assigns contractors as “leads” to respond to MSP case requestsMSP case requests
National Heritage Insurance Company (NHIC)
National Heritage Insurance Company (NHIC)
Adm inistrative Asst.Colle en C erulloH ingham , M A
(781) 7 41-313 6
O perations P erform anc eLana A larco nHingham , M A
Budget/F inancial Reportin gCathy RuccoloH ingham , M A
M SP/O verpaym ent O ps.Denise N oland, M anage r
H ingham , M A(781) 7 41-318 2
Custom er Service - M AKaren G rasso, M anage r
H ingham , M A(781) 7 41-304 4
Custom er Service - NNELorrie Davenp ort, M anage r
B iddeford, M E(207) 2 94-610 1
New En gland AppealsTeresa G iberti, Superviso r
B iddeford, M E(207) 2 94-619 7
NE Education and O utreac hRick Hoove r, M anage r
H ingham , M A(781) 7 41-313 4
Provider Enrollm en tR ichard C ahoon, S uperviso r
H ingham , M A(781) 7 41-305 9
New England M edical Revie wE lizabeth W halen , R .N., M anage r
H ingham , M A(781) 7 41-305 5
EDICarlene V itello, S uperviso r
H ingham , M A(781) 7 41-321 3
CA Education and O utreac hM ichele Kelly, M anage r
Los Angeles, C A(213) 5 93-604 0
NE M edical Polic yPaulette D 'E liaH ingham , M A
(781) 7 41-313 1
Robert H arringto nDirecto r
H ingham , M A(781) 7 41-325 5
National Heritage Insurance CompanyNational Heritage Insurance Company
NHIC General Provider Inquiries (877) 567-3130NHIC General Provider Inquiries (877) 567-3130
NHIC Website: medicarenhic.comNHIC Website: medicarenhic.com
National Heritage Insurance Company
National Heritage Insurance Company
Provider Education and Outreach Provider Education and Outreach
Rick Hoover, ManagerRick Hoover, Manager
(781) 741-3134(781) 741-3134
Medical ReviewMedical Review
Betty Whalen, Manager Betty Whalen, Manager
(781) 741-3055(781) 741-3055
Maine Maine
Brenda BedardBrenda Bedard
(207) 294-6104(207) 294-6104
New HampshireNew Hampshire
Jane Ann FullerJane Ann Fuller
(603) 228-6552(603) 228-6552
VermontVermont
Robin ColettaRobin Coletta
(802) 878-3873(802) 878-3873
robin.coletta@eds,com
Associated Hospital Service
O penA dm inis tra tive
A ssis tant
C hris tine M cC ulloughM SP
A dm inis tra tiveA ssis tant
D iana SaundersM SP
Inves tiga tor
Sadie JonesM SP
Inves tiga tor
M ary FlynnM SP
R ecoverySpecia list
Janet S im onM SP
R ecoverySpecia list
Shelley W alkM SP
R ecoverySpecia list
E llen B arryM SP P rocessor
C ustom er ServiceR epresenta tive
Felic ia JohnsonM SP P rocessor
C ustom er ServiceR epresenta tive
B enita B rownM SP P rocessor
C ustom er ServiceR epresenta tive
Joanne Lespas ioM anager
M SP - M A
M ary R eillyR eceptionist
B renda ArsenaultC ustom er Service
R epresenta tive
M indy JacksonC ustom er Service
R epresenta tive
D enise H eggieC ustom er Service
R epresenta tive
G race H urneyC ustom er Service
R epresenta tive
G ina Pila lasC ustom er Service
R epresenta tive
M aureen W illiamsC ustom er Service
R epresenta tive
C aroline Stra ttonC ustom er Service
R epresenta tive
Lynda H ubbardM anager
C ustom er Service
G erard D onovanB usiness A nalyst
Sandy M acGillivreyB usiness A nalyst
M aureen P ellitte riT es t A na lyst
P aula R obinson-BecklesT es t A na lyst
T es t A na lystR achel K eller
M argare t G riffinM anager
B usiness SystemsT eam
D ebbie T wom eyA dm inis tra tive
A ssis tant
C hris tine SferruzzaQ C
C oordina tor
B arbara B ow denC la ims P rocessor
M aureen C roninC la ims P rocessor
H eather Sm ithC la ims P rocessor
V inh LaC la ims P rocessor
D elia R uppC la ims P rocessor
H ang W ongC la ims P rocessor
A m y TaylorC la ims P rocessor
O penP os ition
G ail M cSweeneyM ail R oomC oordina tor
C heryl H aydenM anagerC la ims
K elli CollagenM edicare
O pera tionsA dm inis tra tor
R enee R ichardM edicare P rovider
T ra in ingC oordina tor
Jean RoyekA dm inis tra tive
A ssis tant
M argaret Q uigley-K ellerC hange M anagem ent
C oordina tor
B arbara V enoD irec tor, C la ims
E sterna l Opera tionsand M SP
Other Contact InformationOther Contact Information
Program Safeguard Contractor Program Safeguard Contractor
New England Benefit Integrity Service Center (BISC) New England Benefit Integrity Service Center (BISC)
Eileen Guiney, UMBIEileen Guiney, UMBI
(781) 741-3207 (781) 741-3207
COB Contractor (800) 999-1188COB Contractor (800) 999-1188
• ““Compliance” means following insurance billing, Compliance” means following insurance billing, claims submission, and documentation rules.claims submission, and documentation rules.
• 1984 Federal Sentencing Guidelines.1984 Federal Sentencing Guidelines.
• ““A comprehensive and formal program designed A comprehensive and formal program designed to prevent, detect, and respond to violations of the to prevent, detect, and respond to violations of the law by an organization’s employees.”law by an organization’s employees.”
Compliance Programs Compliance Programs
• Office of Inspector General has been Office of Inspector General has been developing “Compliance Program Guidances” developing “Compliance Program Guidances” since 1997 and there are now 9 Guidances.since 1997 and there are now 9 Guidances.
• ““The OIG of the DHHS continues in its efforts The OIG of the DHHS continues in its efforts to promote voluntarily developed and to promote voluntarily developed and implemented compliance programs for the implemented compliance programs for the health care industry.”health care industry.”
Compliance ProgramsCompliance Programs
• Laboratories (February, 1997)Laboratories (February, 1997)
• Hospitals (February, 1998)Hospitals (February, 1998)
• Home Health Agencies (August, 1998)Home Health Agencies (August, 1998)
• Third-Party Medical Billing Companies (November, 1998)Third-Party Medical Billing Companies (November, 1998)
• DMEPOS Industry (June, 1999)DMEPOS Industry (June, 1999)
• Hospices (November, 1999)Hospices (November, 1999)
• Medicare+Choice Organizations (January, 2000)Medicare+Choice Organizations (January, 2000)
• Skilled Nursing Facilities (March, 2000)Skilled Nursing Facilities (March, 2000)
• Individual and Small Group Physician Practices (September, 2000)Individual and Small Group Physician Practices (September, 2000)
Nine OIG Compliance GuidancesNine OIG Compliance Guidances
• Draft OIG Compliance Program Guidance for Draft OIG Compliance Program Guidance for Pharmaceutical Manufacturers, October 1, 2002.Pharmaceutical Manufacturers, October 1, 2002.
• Draft OIG Compliance Program Guidance for Ambulance Draft OIG Compliance Program Guidance for Ambulance Suppliers, June 6, 2002.Suppliers, June 6, 2002.
• Hospital Guidance Revision: Solicitation of Comments in Hospital Guidance Revision: Solicitation of Comments in June 18, 2002 June 18, 2002 Federal RegisterFederal Register to address “OPPS to address “OPPS implementation and other significant changes in the hospital implementation and other significant changes in the hospital industry.”industry.”
Upcoming OIG GuidancesUpcoming OIG Guidances
Current State of the IndustryCurrent State of the Industry
1%1% 0% 0%5%
2%2%1%
39%
26%
18%11%
55%
71%
80% 87%
0%
20%
40%
60%
80%
100%
No formalprogram
Programbeing
planned
Programbeing
developed
Activeprogram
1999
2000
2001
2002
2002 Survey of Health Care Compliance Officers
Seven Standards of ComplianceSeven Standards of Compliance
• Code of ConductCode of Conduct
• Compliance OfficerCompliance Officer
• Background ChecksBackground Checks
• Training and EducationTraining and Education
• Reporting Mechanisms, Monitoring and AuditingReporting Mechanisms, Monitoring and Auditing
• Enforcement and DisciplineEnforcement and Discipline
• Investigations and ResponseInvestigations and Response
Compliance Program Effectiveness
Compliance Program Effectiveness
• HCCA Reference Guide on “Evaluating and HCCA Reference Guide on “Evaluating and Improving A Compliance Program”Improving A Compliance Program”
• Adopts the seven standards, Federal Sentencing Adopts the seven standards, Federal Sentencing Guidelines and OIG Guidance as its foundation. Guidelines and OIG Guidance as its foundation.
• Two basic components of a compliance program: Two basic components of a compliance program: structural (process oriented) and substantive structural (process oriented) and substantive (results).(results).
Compliance Program Effectiveness
Compliance Program Effectiveness
To the extent that healthcare providers can demonstrate a program that results in accurately coded, and appropriately documented claims, CMS wishes to recognize in a tangible way the importance of this effort to the solvency and integrity of the Medicare trust fund. We seek to figure how to:
(1) identify the measurable results of an effective compliance program in terms of accurately coded claims, appropriately documented claims and detected inappropriate claims; and
(2) identify ways that CMS can incent the adoption of effective compliance programs by providers.
Compliance Program Effectiveness
Compliance Program Effectiveness
Leslie Norwalk - Chief Operation Officer of CMS
Tim Hill - CFO of CMS
• CMS Leads - • Kim Brandt - (on detail from OIG Office of the General CounselKim Brandt - (on detail from OIG Office of the General Counsel
• Lisa Zone - Benefit Integrity and Law Enforcement Liaison Dir.Lisa Zone - Benefit Integrity and Law Enforcement Liaison Dir.
• Jim Bryant - Boston RO [email protected] Bryant - Boston RO [email protected]
617.565.1331617.565.1331
• Lew Morris, OIGLew Morris, OIG
• Lori Pellicioni Lori Pellicioni
• David OrbachDavid Orbach