Download - VBH-PA Provider Self-Audit Protocol...A psychiatric outpatient clinic bills for a medication administration visit when no medication was administered VBH -PA Provider Self Audit Protocol

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VBH-PA Provider

Self-Audit Protocol

Jennifer Putt, CFE

Manager of Program Integrity

August 12, 2016

VBH-PA Provider Self-Audit Protocol

Topics for Today’s Presentation

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Background and Requirements for Provider Self-Audits

Examples of Inappropriate Payments Suitable for Provider Self-Audits

Types of Provider Self-Audits



Background and

Requirements

for Provider

Self-Audits

3VBH-PA Provider Self-Audit Protocol


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Federal Requirements:

OIG Department of Health and Human Services: Self-Disclosure Protocol:

Provider Self-Disclosure

HHS Contractors and Self-Disclosures

HHS Grantee Self-Disclosure

Self-disclosure can reduce the civil penalties and corrective actions that can be imposed for overpayments

https://oig.hhs.gov/compliance/self-disclosure-info/index.asp


https://oig.hhs.gov/compliance/self-disclosure-info/index.asp


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OIG Provider Self-Disclosure

OIG self-audit protocol introduced in 1998

Process for health care providers to voluntarily identify, disclose, and resolve instances of potential fraud

OIG emphasizes that the health care industry has a legal and ethical duty to report overpayment and potential fraud, which includes the following obligations:

Taking measures to detect and prevent fraudulent and abusive activities

Implementing specific procedures and mechanisms to investigate fraud

Resolving and correcting to prevent future instances of potential fraud



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OIG Provider Self-Disclosure

Benefits of “good faith” disclosures and cooperation with the OIG:

Provides evidence of a robust compliance program

Allows for integrity agreements instead of exclusion

Allows for lower multiplier and single damages

Prevents suspension of future payments

Reduces OIG investigations



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Pennsylvania Requirements

Medical Assistance Bulletin 99-02-13, The Bureau of Program Integrity and the Medical Assistance Provider Self-Audit Protocol:

Requires all providers to conduct self-audits and return overpayments in accordance with the protocol

Requires all Managed Care Organizations to have provider self-audit protocols and processes for HealthChoices

http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_004259.pdf


http://www.dhs.pa.gov/cs/groups/webcontent/documents/bulletin_admin/d_004259.pdf


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Medical Assistance Bulletin 99-02-13

BPI suggests that providers consider the following recommendations to ensure compliance with MA regulations and avoid possible sanctions and penalties:

Providers should be aware of billing requirements and compensable services under the MA Program.

Providers, to the extent practicable, should adopt and implement compliance plans to ensure that they remain in compliance with MA regulations.

As part of a compliance plan, providers should periodically conduct self-audits to ensure compliance with MA regulations.

To the extent that overpayments are identified, providers should utilize the MA Provider Self-Audit Protocol to facilitate the return of overpayments.



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BPI can take the following actions for providers that do not identify and return overpayments:

Educational and training letters;

Recover improperly paid funds;

Terminate a provider’s provider agreement and preclude a provider’s direct and indirect participation in the MA Program;

Refer the case to the Attorney General’s MFCU or other appropriate criminal law enforcement agency;

Refer a case to an appropriate civil agency

Seek a civil monetary penalty amounting to twice the overpaid amount plus interest; or

Recommend internal policy changes to improve and/or clarify program standards.



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BPI states that providers will receive the following benefits from self-disclosure:

DHS will not seek double (or triple) damages, but will accept repayment without penalty if self-audits are voluntary and identified by provider prior to an oversight audit

DHS can provide assistance and training during the self-audit processes



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BPI states that MCOs should have self-audit protocols for providers:

MCOs are required to have a provider self-audit protocol

MCOs are required to educate providers on self-audits

MCOs should work collaboratively with BPI and DHS on provider self-audits



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Pennsylvania Requirements

PA Department of Human Services (DHS) Bureau of Program Integrity (BPI) Information on provider self-audit protocols:

Provides options for conducting self-audits directly with DHS and BPI

VBH-PA has a similar provider self-audit protocol for HealthChoices services and members

http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/medicalassistanceproviderselfauditprotocol/


http://www.dhs.pa.gov/learnaboutdhs/fraudandabuse/medicalassistanceproviderselfauditprotocol/

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Examples of

Inappropriate

Payments Suitable

for Provider Self-

Audits


Fraud, Waste, and Abuse

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Fraud must be reported and will result in overpayments that providers need to return

Fraud can result in civil and criminal penalties

Fraud may be identified through self-audits

Fraud: Any intentional deception or misrepresentation made by an entity or person in a capitated MCO, Primary Care Case Management (PCCM), or other managed care setting with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting



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Providers must return overpayments from abuse and waste within 60 days or the overpayments held can be considered fraud

Abuse: Any practices in a capitated MCO, Primary Care Case Management (PCCM) program, or other managed care setting that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA Program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized standards or contractual obligations (including the terms of the PA HC PSR, contracts, and requirements of state or federal regulations) for health care in the managed care setting

Waste: Thoughtless or careless expenditure, consumption, mismanagement, use or squandering of healthcare resources, including incurring costs because of inefficient or ineffective practices, systems or controls



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Fraud, waste, and abuse that can result in provider overpayments:

Any services that are out of compliance with PA or Federal Code

Any services that are out of compliance with PA Medical Assistance Payment Regulations

Any services that do not meet the VBH-PA Provider Manual requirements or minimum documentation standards

Any services that are not within the scope of practice standards or service descriptions



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A psychiatric inpatient hospital provider bills and received payment for primary Drug and Alcohol services not payable to a psychiatric hospital or hospital psychiatric unit

A provider bills MA with an incorrect prescriber’s or practitioner’s license number

A mental health outpatient clinic determines that psychotherapy groups had more than 10 participants, when payment regulations require psychotherapy groups to be for 2 to 10 members for at least a continuous 60 minutes



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A family based mental health services or behavioral rehabilitation provider discovers that clinicians are billing for travel or no shows

A psychiatric partial hospitalization program bills for time spent transporting the client to and/or from the partial program or for time spent in activities away from the licensed site



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Two or more physicians involved in rendering an inpatient service bills different procedure codes for the same service

A methadone maintenance provider bills for services provided prior to the clinic supervisory physician’s examination/evaluation and/or treatment plan

A psychiatric outpatient clinic bills for a medication administration visit when no medication was administered



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Self-Audit and Adjustments for Errors without Patterns

Individual Claims Adjustments:

Documentation errors and overpayments that are limited to a specific occurrence through standard monitoring and auditing

Errors have no patterns and are not repetitive

Error rate is below a pre-determined threshold

Example: During a quarterly review of 25 member records, a provider discovers the following: 23 member records have no errors,1 member record has incomplete treatment plan review, and 1 member record is missing a progress note

Through the self-audit process, the provider will request specific claims adjustments for the claims associated with the incomplete treatment plan and the claim for the missing progress note



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Self-Audit and Adjustments for Errors with Patterns or Repeated Occurrences

100% Review of Claims:

Documentation errors and overpayments are repetitive and consistent through the review

Error rate is above a pre-determined threshold

Case-by-case review of claims is administratively feasible and cost-effective

Example: During a quarterly review of 25 member records, a provider discovers the following: 20 member records have no findings and 5 member records has missing encounter forms for various dates of service

The provider determines the missing encounter forms are from a new clinician that has only been providing service for 6 months

The provider decides to review 100% of the new clinician’s claims to determine the error rate of missing encounter forms to calculate the correct overpayment and implement corrective actions



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Provider-Developed Self-Audit Work Plan:

Documentation errors and overpayments are repetitive and consistent through the review

Case-by-case review of claims is NOT administratively feasible and cost-effective

The provider must project the actual error rate and overpayments

Example: During an on-site CMS review of 100 claims, CMS discovers the following: 60 claims have no findings and 40 claims were for group services that had more than 10 participants

The provider determines a case-by-case review of claims is NOT administratively feasible and cost-effective because there are 10,000 claims that require member record reviews

The provider decides to submit a plan to use CMS error rate and extrapolation to calculate overpayments and implement corrective actions


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VBH-PA

Provider

Self-Audit

Protocol



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The VBH-PA Provider Self-Audit Protocol provides detailed instructions and is available at the following:

http://www.vbh-pa.com/fraud/pdfs/Provider-Self-Audit-Protocol.pdf

VBH-PA allows providers to select the methodology of self-audit based on the types of self-audits:

Self-Audit and Adjustments for Errors without Patterns

Individual Claims Adjustments


100% Review of Claims

Provider-Developed Self-Audit Work Plan


http://www.vbh-pa.com/fraud/pdfs/Provider-Self-Audit-Protocol.pdf


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The VBH-PA Provider Self-Audit Protocol provides instructions on how to use each of the forms available online:

http://www.vbh-pa.com/fraud_abuse.htm

Attachment #1: VBH-PA Claims Spreadsheet

Attachment #2: VBH-PA Provider Self-Audit Referral Form

Attachment #3: VBH-PA Provider Audit Response

Attachment #4: VBH-PA Provider Self-Audit Work Plan Form




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Additional Tips for the VBH-PA Provider Self-Audit Protocol:

All information related to self-audits should be sent to the following email: [email protected]

If you do not have encrypted email, you must contact the above email before sending member information

A VBH-PA Program Integrity Auditor will be assigned to each provider self-audit and will assist the provider through the steps of the protocol

Please visit the VBH-PA Program Integrity Contact Information on Fraud and Abuse webpage


mailto:[email protected]

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Review of VBH-PA

Provider Self-

Audit Protocol

Giving Value Back to the Provider 2016



Review Documents on VBH-PA Webpage


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Questions?


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Thank you


Download - VBH-PA Provider Self-Audit Protocol...A psychiatric outpatient clinic bills for a medication administration visit when no medication was administered VBH -PA Provider Self Audit Protocol

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