new jersey department of human services di i i f m di...

New Jersey Department of Human Services Di i i f M di l A i t d H lth S iDivision of Medical Assistance and Health Services

Medicaid Utilization Reviews

Provider Orientation

2010

AgendaAgenda1. Introductions2. Overview3 Utilization Review3. Utilization Review4. Implementation Plan

Organizational Chart Recruiting Physician Panel Training Technology

5. Meeting with Current Contractor(s)6. Provider Relation

M ti ith H it l A i ti Meeting with Hospital Association Mailings/Meetings

7. Operations Review criteria – Milliman On-site vs Off-site review On-site vs Off-site review Reports Forms/Letters Delegated/Non-delegated notifications

8. QuestionsQ

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Introductions: Permedion-HMSIntroductions: Permedion HMS Dennis Gramlich, Vice President, Permedion

Kevin Lee, Regional Vice President

David Sand MD, Chief Medical Officer

Joseph Steeger MD PhD, Medical Director

Patricia Ratwani RN, Clinical ReviewPatricia Ratwani RN, Clinical Review

Linda Freites RN, Project Manager

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Introductions: MFD/DMAHSIntroductions: MFD/DMAHS Karen Chester RN, Regional Staff Nurse, Office of Reimbursement,

DMAHSDMAHS

Richard Hurd, Acting Chief of Staff, DMAHS

Mark Moskovitz, Deputy Director, Office of Comptroller, Medicaid

Fraud Division (MFD)

Pamela Orton RN, Healthcare Administrator, DMAHS

Jennifer Petrino, Administrator, Contract Compliance, DMAHS

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Overview of HMSOverview of HMS Cost containment services for 37 state Medicaid agencies, CHIP,

Child Support, Pharmacy Assistance, CMS Coordination of benefits, program integrity, and other recovery and

cost savings projectscost savings projects 1,100 employees in 26 offices Multiple contracts with NJ since 1986

Oth NJ j t Other NJ projects:• Third Party Liability 1986 – Present; $1.4B Recovery • Cardiac Surgery 2009 – Present • Rx and DME Audit 2010 - Present

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Breadth of HMS Services

Clinical• Policy review

Utili ti t• Utilization management• Pre-certification review• DRG review/validation• Coding review• Compliance audit Compliance• Medical review• Quality review

Compliance•Fraud & abuse detection•Pharmacy audit•PBM audit•Behavioral health audit

Financial•TPL insurer data matching•TPL billing and recovery•Casualty/Estate recovery•Credit balances

•Training

•Credit balances•Data mining for overpayments•Eligibility verification services•Eligibility decision support•HIPP/premium management

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•Asset/Income verification•Outreach to uninsured

About Permedion

Wholly owned subsidiary of HMS since October 2007

Designated as a QIO-like entity by CMS

Accredited by URAC for both Utilization Management and y g

Independent Review

IRO for 12 States – Commercial Insurance Appealspp

110 Employees

600 Board Certified & Licensed Physicians600 Board Certified & Licensed Physicians

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Utilization Review ServicesExperience and Approach

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Utilization Review Experience

Colorado South Carolina

Illinois

South Carolina

Virginia

Kentucky North Carolina

New Jersey Massachusetts

Ohio

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Approachpp1. Review of Billing and Reimbursement Policies

• Clinical Guidelines• Audit Regulations• Data Mining Process Updated to Reflect Parameters

2 Case Selection2. Case Selection• Random Sample for Utilization Review• Random Sample for DRG Validation

3. Provider Medical Record Request• All Letters Sent to Specific Individual• Attempt to Accommodate Provider Workload Issues• Courtesy Call• On Site Reviews Scheduled for Selected Facilities• Electronic Record Intake Option

All L tt G t d/T k d i S t

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• All Letters Generated/Tracked in System

Approach (continued)4. Clinical/Coding Review

• Medical Record Abstraction by RN• RN and Certified Coders• RN and Certified Coders• System Ensures Accurate Abstraction• Quality Review for all Cases

5 Ph i i R i5. Physician Review• Required for medical necessity or DRG change• NJ physician panel

6. Notification Letter • Clinical summary and detailed rationale• Educational guidance as appropriate

7. Reconsideration & Appeal• Reconsideration to Permedion• Clinical issues referred to 2nd specialty-matched physician

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Clinical issues referred to 2 , specialty matched physician• Fair Hearings to State

Approach (continued)Approach (continued)8. Collection & Recoupment

• Claim payment recouped• Provider to re-bill correctly with correct coding and/or for

appropriate setting

9. Identification of Trends• Based on errors, review• Data mining to confirm trend metrics• Data mining to confirm trend, metrics

10. Provider Education• Specific education through notification letter• Specific education through notification letter• Error trend education through provider bulletins• One-on-one interaction

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Case Review ProcessStart

Identify claims for review

Onsite >20 records @ one

provider

Send claims toPITrack Nurse

Reviewer

Onsite Review of Coder issues

Board Certified

Physician

Medical record review

Coder – DRGDenials

repriced and letter produced

Nurse produces medical

necessity denial letters

Denial

Referral

Denial

Offsite

Send record request letter

(Onsite/Offsite)

Assign nurses for onsite

review

medical record

Nurse Reviewer

Desk Review ofmedical record

Coder

Review referredmedical records

Claim dropped – no letter required

Coder issues billing denial –no physician

review required

letter produced

Submit denial letter to

provider and post to web

OnsiteDenial

Approved

End

Call hospital on Day 20 of request

Send request letter and lists to providers(30 D f

Deliver records to nurse

reviewersTechnical denial

Technical denial letter created

and client recoups claims

Does not submit records

1233a 012610

(30 Days for response)

ProviderSubmitsRecords

1233a.012610

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Reconsideration Process

Receive appeals within 45 days of

determination letter

Board CertifiedPhysician

Medical Record Review

Start Coder/Nurse

Review chart and make determination

within 30 days of receipt of appeal

letter and additional information

Referral

Document and/orcalculate results

Written rationale documented on appeals letter

Uphold Results

OverturnResults

Appeal

Provider initiatesappeal

Send appeal results letter to Provider and

post Client letters to web

End

1232a.012610

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ImplementationImplementationPlanPlan

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Implementation Plan

Approach Approach• Project Management

• Gantt Charts

• Frequent, effective communicationseque , e ec e co u ca o s

• Team approach

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Implementation PlanImplementation Plan PhasesPhases

• Transition• Facilities• Technology• Staffing• Quality Assurance• Quality Assurance• Contract Management• Training• Utilization Management Program

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Implementation PlanImplementation Plan

Staffing Plan: Milestones Staffing Plan: Milestones• Recruit/hire key personnel• Hire operational staffHire operational staff• Complete staff training

Training for initial hires completed by October 30, 2010

2020


Training Plan: Milestones Training Plan: Milestones • Revise corporate orientation programs

• Develop contract orientation program Including orientation to DMAHS Customer service trainingCustomer service training

• Develop review activity training program in

Scompliance with DMAHS regulations

• Develop position-specific training program

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Office Space and Facilities Plan MilestonesOffice Space and Facilities Plan Milestones• Assessed Trenton, NJ office

Utilization of excess capacity

• Acquire additional space

60 – 90 days

• Complete equipment acquisitionp q p q

• Complete facilities set-up

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Technology Plan HMS has in-place technology and infrastructure to receive project

related data files

Technology Plan

related data files• Existing Extranet Business Partner Agreement with DHS• Existing Firewall hardware installed at DHSS• Existing high speed data lines to DHS, and to the Medicaid Fiscal g g

Intermediary, both Mercerville, NJ and Salt Lake City, Utah Data-centers

HMS receives • Paid Claim Files weekly• Paid Claim Files weekly• Provider File Quarterly

HMS has an existing Disaster Recovery Plan HMS is familiar with FD 999 Claims Adjustment Form HMS is familiar with FD-999 Claims Adjustment Form HMS is capable to implement electronic adjustments conforming to

DMAHS requirements and Fiscal Agent specifications

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Meeting with Current Contractor(s)g ( )

Turnover PlanTurnover Plan

Transfer Date

Clean Transfer vs. Overlap

Identify Other Action Items

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Provider RelationsProvider RelationsOrientation to Permedion-HMS and the

Review Program• Medical Review Process• Physician Panel• Physician Panel• Key Contacts (Project Manager, Quality

Management Supervisor)

Ongoing• Newsletter• Website• Feedback• Events• Events• One-on-one

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New Jersey Hospital Associationy p

Identify contactsEstablish working relationshipg pAssist with provider orientationQuarterly conferenceQuarterly conferenceWork collaboratively on provider issues

d d tiand education

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OperationsOperations

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Operations – Review CriteriaOperations Review Criteria

Milliman Care GuidelinesMilliman Care Guidelines• Evidence-based

• Used in most Permedion UR contracts

• Better fit with Medicaid population for inpatient vs

outpatient services

• Easier to use for retrospective review• Easier to use for retrospective review

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Operations – Retrospective ReviewOperations – Retrospective Review

Sample of reviews based on number ofSample of reviews based on number of dischargesF f i b d b fFrequency of review based on number of discharges.Review of days to determine appropriate

statusQuality review

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Operations – On-site vs. Off-siteOperations On site vs. Off site

State to determineOff-site:

• Ability to send records electronicallyy y• Less intrusion on provider operations

On-site:• Flexible in scheduling• May be intermittent

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Operations – Forms/LettersOperations Forms/Letters

All forms and letters going to providers g g pwill:

• Be provided to DMAHS for review/approval• Contain appropriate references• Be posted to secure web page for DMAHS

accessaccess

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MARKMARK MOSKOVITZMOSKOVITZMARK MARK MOSKOVITZMOSKOVITZ

DEPUTY DIRECTOR DEPUTY DIRECTOR MEDICAID FRAUD DIVISIONMEDICAID FRAUD DIVISIONMEDICAID FRAUD DIVISION MEDICAID FRAUD DIVISION

OFFICE OF THE STATE OFFICE OF THE STATE COMPTROLLERCOMPTROLLERCOMPTROLLERCOMPTROLLER

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MEDICAID PROGRAMMEDICAID PROGRAMINTEGRITY AND PROTECTIONINTEGRITY AND PROTECTIONINTEGRITY AND PROTECTION INTEGRITY AND PROTECTION

ACTACT [C.30:4D[C.30:4D--53 et 53 et seqseq]]

Act that established the Office of Act that established the Office of Medicaid Inspector General in NewMedicaid Inspector General in NewMedicaid Inspector General in New Medicaid Inspector General in New JerseyJersey

Signed into law on March 16Signed into law on March 16 20072007 Signed into law on March 16, Signed into law on March 16, 20072007 OMIG consolidated into the Medicaid OMIG consolidated into the Medicaid

Fraud Division of the Comptroller’sFraud Division of the Comptroller’sFraud Division of the Comptroller s Fraud Division of the Comptroller s Office on June 30, 2010, with all the Office on June 30, 2010, with all the powers of the OMIG.powers of the OMIG.powers of the OMIG.powers of the OMIG.

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MFDMFD RESPONSIBILITIESRESPONSIBILITIESMFD MFD RESPONSIBILITIESRESPONSIBILITIES

Detect prevent and investigate fraud andDetect prevent and investigate fraud and Detect, prevent, and investigate fraud and Detect, prevent, and investigate fraud and abuseabuseRecover improperly expended MedicaidRecover improperly expended Medicaid Recover improperly expended Medicaid Recover improperly expended Medicaid fundsfundsE f M di id R l d R l tiE f M di id R l d R l ti Enforce Medicaid Rules and RegulationsEnforce Medicaid Rules and Regulations

Audit cost reports and claimsAudit cost reports and claims Review quality of care given to Review quality of care given to

beneficiaries beneficiaries

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Refer criminal prosecutions to theRefer criminal prosecutions to the Refer criminal prosecutions to the Refer criminal prosecutions to the Attorney General’s officeAttorney General’s office

Oversee edits to the New Jersey Medicaid Oversee edits to the New Jersey Medicaid Management Information System Management Information System (NJMMIS)(NJMMIS)

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WU3

WU3 text here is too small. should break it up into two slidesWindows User, 01/31/2010


Conduct educational programs forConduct educational programs for Conduct educational programs for Conduct educational programs for Medicaid providers, vendors, contractors, Medicaid providers, vendors, contractors, and recipientsand recipientsand recipientsand recipients

Issue a report on the MFD’s activities, as a Issue a report on the MFD’s activities, as a part of the Comptroller’s annual report topart of the Comptroller’s annual report topart of the Comptroller s annual report to part of the Comptroller s annual report to Governor and the Legislature. Governor and the Legislature. R f i f ti d id tR f i f ti d id t Refer information and evidence to Refer information and evidence to regulatory agencies and professional and regulatory agencies and professional and

ti l li i b dti l li i b doccupational licensing boards occupational licensing boards 37

KEY DEFINITIONSKEY DEFINITIONSKEY DEFINITIONSKEY DEFINITIONS

Statute defines fraud as:Statute defines fraud as: Statute defines fraud as:Statute defines fraud as: “an intentional deception or “an intentional deception or

misrepresentation made by any personmade by any personmisrepresentation made by any personmade by any person with the knowledge that the deception with the knowledge that the deception

ldld lt ilt i th i d b fitth i d b fitcouldcould result in result in somesome unauthorized benefit unauthorized benefit to that person or another person, to that person or another person, i l di t th t tit t f di l di t th t tit t f dincluding any act that constitutes fraud including any act that constitutes fraud under applicable federal or State law.”under applicable federal or State law.”

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Definition of abuse:Definition of abuse: Definition of abuse:Definition of abuse:1.1. Provider Provider practices that are practices that are inconsistentinconsistent with with

sound fiscal, business, or medical practicessound fiscal, business, or medical practicessound fiscal, business, or medical practices sound fiscal, business, or medical practices and;and;

2.2. Result Result in in unnecessary costsunnecessary costs to Medicaid to Medicaid or; or; yy ;;3.3. In In reimbursement for services that are not reimbursement for services that are not

medically necessary medically necessary oror4.4. Fail Fail to meet professionally recognized to meet professionally recognized

standards for health care. standards for health care. 5.5. The The term also includes recipient practices that term also includes recipient practices that

result in unnecessary costs to Medicaid.” result in unnecessary costs to Medicaid.” 39


The statute defines Medicaid to includeThe statute defines Medicaid to include The statute defines Medicaid to include The statute defines Medicaid to include both the Medicaid program and the N.J. both the Medicaid program and the N.J. FamilyCare ProgramFamilyCare ProgramFamilyCare ProgramFamilyCare Program

Ch it C i l d d f t t tCh it C i l d d f t t t Charity Care is excluded from statuteCharity Care is excluded from statute

However, a separate statute, passed in However, a separate statute, passed in December 2007, gives our office power to December 2007, gives our office power to , g p, g pinvestigate charity care fraudinvestigate charity care fraud

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ORGANIZATION OF THE MFDORGANIZATION OF THE MFDORGANIZATION OF THE MFDORGANIZATION OF THE MFD

REGULATORYREGULATORY REGULATORY REGULATORY INVESTIGATIONS INVESTIGATIONS

FISCAL INTEGRITYFISCAL INTEGRITY FISCAL INTEGRITY FISCAL INTEGRITY Audit UnitAudit Unit Third Party Liability UnitThird Party Liability Unit Data Mining UnitData Mining Unit Recovery UnitRecovery Unit

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GOALSGOALSGOALSGOALS

Ferret out the fraud and abuse in the system, and there’s Ferret out the fraud and abuse in the system, and there’s ten billion dollars in the system. Last year, Medicaid ten billion dollars in the system. Last year, Medicaid recoveries and cost savings topped 270 million in Newrecoveries and cost savings topped 270 million in Newrecoveries and cost savings topped 270 million in New recoveries and cost savings topped 270 million in New Jersey. Jersey.

H b t dit d i h d lH b t dit d i h d l Have a robust audit program and review scheduleHave a robust audit program and review schedule--provides a deterrent effect (can’t just pay and chase).provides a deterrent effect (can’t just pay and chase).

Review provider areas that have not been reviewed in Review provider areas that have not been reviewed in quite awhile.quite awhile.

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MFD HOSPITAL INITIATIVESMFD HOSPITAL INITIATIVESMFD HOSPITAL INITIATIVESMFD HOSPITAL INITIATIVES

UTILIZATION AND DRG AUDITSUTILIZATION AND DRG AUDITS UTILIZATION AND DRG AUDITSUTILIZATION AND DRG AUDITS DMAHS has contracted with Permedion to DMAHS has contracted with Permedion to

conduct these auditsconduct these auditsconduct these audits.conduct these audits. Audits will begin in November.Audits will begin in November. UR Audits will include units that had beenUR Audits will include units that had been UR Audits will include units that had been UR Audits will include units that had been

omitted before, i.e. psychiatric & omitted before, i.e. psychiatric & rehabilitation.rehabilitation.

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Monthly meetings with Permedion, DMAHS,Monthly meetings with Permedion, DMAHS, Monthly meetings with Permedion, DMAHS, Monthly meetings with Permedion, DMAHS, and the MFD to review audit findings, and and the MFD to review audit findings, and where there is evidence of fraud, waste, or where there is evidence of fraud, waste, or abuse, to refer them to the MFD.abuse, to refer them to the MFD.

May result in an expanded audit and/or May result in an expanded audit and/or investigation.investigation.

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COST REPORT AUDITS WILL FOCUS ON:COST REPORT AUDITS WILL FOCUS ON: COST REPORT AUDITS WILL FOCUS ON:COST REPORT AUDITS WILL FOCUS ON: Physician payments for direct patient carePhysician payments for direct patient care Administrative servicesAdministrative services Administrative services Administrative services Rental space for private officesRental space for private offices

Payments for undocumented or unnecessaryPayments for undocumented or unnecessary Payments for undocumented or unnecessary Payments for undocumented or unnecessary servicesservicesPhysician practice subsidiesPhysician practice subsidies Physician practice subsidiesPhysician practice subsidies

Physician contracts, including fair market Physician contracts, including fair market analysis of physician servicesanalysis of physician servicesanalysis of physician servicesanalysis of physician services

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Any questions?Any questions?Any questions?Any questions?

Office location is:Office location is: P O Box 025 TrentonP O Box 025 Trenton Office location is: Office location is: P.O. Box 025, TrentonP.O. Box 025, Trenton, , N.J. N.J. 0862508625

Phone Number: (609) 826Phone Number: (609) 826--47004700 My Number: (609) 777My Number: (609) 777--41674167

Website: Website: www.nj.gov/comptroller/divisions/medicaid/index.htmlwww.nj.gov/comptroller/divisions/medicaid/index.htmlj g / p / / /j g / p / / /

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Open Discussion and QuestionsOpe scuss o a d Quest o s

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