Office of Inspector General2013

Texas Oral Health Coalition, Oral Health SummitNovember 22, 2013

Office of Inspector General2013

Texas Oral Health Coalition, Oral Health SummitNovember 22, 2013

Detecting and Decreasing Waste, Abuse & Fraud

Detecting and Decreasing Waste, Abuse & Fraud

Office of Inspector GeneralOffice of Inspector General

EXECUTIVE COMMISSIONER

Health & Human ServicesCommission

COMMISSIONER

DADSAging & Disability

Services

COMMISSIONER COMMISSIONER COMMISSIONER

Assistive & RehabServices

Family & ProtectiveServices

State HealthServices

DARSDFPSDSHS

InspectorInspectorGeneralGeneral

Governor

Areas of ResponsibilityAreas of Responsibility

Burdens of Proof:

• Office of Inspector General (OIG)Office of Inspector General (OIG)

Administrative – preponderance of evidence

• Office of Attorney General (OAG)Office of Attorney General (OAG)

Civil & Criminal – culpable mental state

• Each recognize various levels of involvement:

Knowingly

Intentionally

Recklessly

Willfully

Negligence

Waste, Abuse & Fraud

The Causes

Waste, Abuse & Fraud

The Causes

What is Waste, Abuse, & Fraud?What is Waste, Abuse, & Fraud?

• WastePractices that a reasonably prudent person would deem careless or that would allow inefficient use of resources, items, or services.

• AbusePractices that are inconsistent with sound fiscal, business, or medical practices and that result in unnecessary program cost or in reimbursement for services that are not medically necessary, do not meet professionally recognized standards for health care, or do not meet standards required by contract, statute, regulation, previously sent interpretations of any of the items listed, or authorized governmental explanations of any of the foregoing.

• FraudAny act that constitutes fraud under applicable federal or state law, including any intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to that person or some other person. Fraud may include any acts prohibited by the Texas Human Resources Code, Chapter 36 or Texas Penal Code, Chapter 35A.

‘Red Flags’ of Fraud‘Red Flags’ of Fraud

Personal Pressures

• Finances.

• Personal Feelings.

Personal Characteristics

• Rationalization of behavior.

• Lack of stability.

Organizational Opportunities

• Accounting practices.

• Firm characteristics.

Organizational Pressures

• Business decisions.

• Legal difficulties.

Institute of Internal Auditors – Ethics Panel:

Who Commits Waste, Abuse & Fraud?Who Commits Waste, Abuse & Fraud?

Anybody can!

– State employees.

– Managed Care Organizations.

– Contractors and subcontractors.

– Providers and their staffs.

– Recipients and beneficiaries.

Waste, Abuse & Fraud

The Problem

Waste, Abuse & Fraud

The Problem

Provider FraudProvider Fraud

Main Concerns:

• Inflating bills.

• Double-billing.

• Up-coding / unbundling.

• Billing for unnecessary services.

• Billing for services never rendered.

• Reporting phantom visits.

• Inappropriate cost shifting.

• Billing for service previously provided.

Durable Medical Equipment FraudDurable Medical Equipment Fraud

Main Concerns:

• Drop-shipping supplies.

• Defective wheelchairs and other equipment.

• Fraudulent billing.

• Not checking with clients.

• Falsification of signatures.

• Solicitation.

• Documentation.

Medical Transportation FraudMedical Transportation Fraud

Main Concerns:

• Emergency vs. Non-Emergency.

• Misrepresenting the client’s condition.

• Billing for en-route supplies when none used.

• Indicating ‘severely disabled’ when not.

• Cancelled requests or no-shows.

• No Medicaid-covered services received.

• False claims for transport outside county.

• False authorization.

Healthcare Organization FraudHealthcare Organization Fraud

Main Concerns:

• Procurement of managed care contracts.

• Marketing, enrollment, and de-enrollment.

• Underutilization.

• Claims submission and billing procedures.

• Antitrust violations.

• Fraud or abuse in the FFS component.

• Embezzlement and theft.

Beneficiary FraudBeneficiary Fraud

Main Concerns:

Eligibility:

• Income – Resources.

• Family composition / Residency.

Misuse of Benefits:

• Recipient card sharing.

• Misuse of medical services.

• Misuse of prescription medications.

• Altering of prescriptions.

• Trafficking in Lone Star Cards.

• Failure to report private insurance.

Waste, Abuse, & Fraud

The Process

Waste, Abuse, & Fraud

The Process

The Usual ProcessThe Usual Process

• Allegation / Report

• Investigation / Finding

• Hearing / Trial

• Civil Penalties / Exclusion

Investigation ProcessInvestigation Process

Medicaid Provider Integrity

• Each complaint is reviewed by an

intake investigator. The results can

be one or more of the following:

- case closure

- provider education

- referral to a licensure board

- payment hold

- referral to the Attorney General

- full scale investigation

Potential RemediesPotential Remedies

Sanctions• Recoupment of Overpayments

• Civil Monetary Penalties for False Claims

• Exclusion

• Payment Hold

• Contract Cancellation

• Restricted Reimbursement

• Recoupment of Other Funds

Administrative Actions• Pre-Payment Holds

• Educational Sessions

• Prior Authorization

• Corrective Action Meetings

• Surety Bonds

Waste, Abuse & Fraud

The Solution

Waste, Abuse & Fraud

The Solution

Eliminate WAF: Plan & ControlEliminate WAF: Plan & Control

• Develop a Prevention Plan:

- Designate a key Compliance Officer

or Compliance Team.

- Outline specific roles / responsibilities.

- Specify the scope of authority.

- Define relationship with other areas

(i.e. OIG, TMHP, etc.).

- Identify and measure risks.

- Analyze all aspects of your program.

- What are your ‘Red Flags’?

- What factors are critical?

- Identify what is in your direct control,

and what isn’t.

Eliminate WAF: Educate & ImplementEliminate WAF: Educate & Implement

• Develop Learning Functions:

- Train in awareness and prevention.

- Intake staff in telephone skills, probing

questions, program specifics.

- MTP clients, Transportation provider,

Medical providers in responsibilities.

- Implement and monitor controls.

- Create a ‘triage’ process to assess.

- Have regular discussions on potential

WAF issues and responses.

- Identify how you know you are

succeeding.

Eliminate WAF: Document & BuildEliminate WAF: Document & Build

• Develop Integrity Functions:

- Document everything.

- Build good data collection &

record keeping into your processes.

- Encourage continuous improvement.

- Keep current and active in state and

federal trends, initiative, and statutes

that impact your program.

- Ask, “What if . . .” to create ideas, build

innovation, and improve service.

- Don’t get stuck in, “We’ve always done

it that way.”

Waste, Abuse & Fraud

Responsibility to Report

Waste, Abuse & Fraud

Responsibility to Report

Why Report Waste, Abuse & Fraud?Why Report Waste, Abuse & Fraud?

• It cheats everyone.All these activities cost taxpayers and good providers, siphonmoney from patient care, and increase state, federal, andmanaged care oversight and investigative costs.

• It hurts Medicaid clients.These activities can result in individuals not receiving carethat is medically necessary, or receiving unnecessary or even harmful care.

• It’s illegal.Fraud or abuse can result in civil or criminal liability. Notonly is the person who knowingly falsifies records or claimsresponsible, so is the person telling them to do so and anyonewho knew or should reasonably have known what was happening.

Excessive and below standard of care dental services

Falsified Documentation

Lower Right Lower Left

Falsified Documentation

Panoramic x-ray Intra-oral of lower arch

Inaccurate Documentation

2009 Bitewing x-rays 2010 Bitewing x-rays

Questions/Contact Information

Linda M. Altenhoff, DDS

Chief Dental Officer

512.491.1106

Linda.Altenhoff@hhsc.state.tx.us

ContactContact

• OIG Website

https://oig.hhsc.state.tx.us/OIG_home.aspx

• OIG Hotline

1-800-436-6184

• OIG Training CoordinatorTodd Shaw

512-491-2059

todd.shaw@hhsc.state.tx.us