the office of the medicaid inspector general combating .... oi… · the office of the medicaid...
TRANSCRIPT
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The Office of the Medicaid Inspector General
Combating Fraud, Waste, and Abuse in the
Arkansas Medicaid Program
Bart Dickinson, Chief Counsel
Office of the Medicaid Inspector General
The Office of Medicaid Inspector General shall
prevent, detect, and investigate fraud, and
abuse within the medical assistance program.
- Ark. Code Ann. §20-77-2505
The Office of the Medicaid Inspector General
fulfills the federal program integrity
requirement to ensure compliance, efficiency,
and accountability within the Medicaid
program by detecting and preventing fraud,
waste, and abuse under - 42 CFR §455 et al.
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OMIG focusVerify Medicaid services and claims were furnished and
properly billed for eligible beneficiaries;
Recover improperly expended payments;
Report fraud and abuse to appropriate law enforcement;
Recommend and implement changes to the Medicaid
program.
Who is HFMA?
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OMIG Agency Work plan
• Audit and Review Medicaid Providers
• Federal Program Integrity requirements
• Investigate, Suspend, and Exclude Providers
• Recommend and Implement reform
• Develop Initiatives to curb Fraud, Waste, and
Abuse in Medicaid programs
• Educate Medicaid Providers
Data Analysis and Audit Selection
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Selecting Medicaid Providers for Audit and Review
Highest Billers = Field Audit
Mid Level Billers = Self Audit Req.
High Billers = Desk Audit
Low Level Billers = Awareness Let.
Program Review / Change
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$0.00
$500,000.00
$1,000,000.00
$1,500,000.00
$2,000,000.00
$2,500,000.00
$3,000,000.00
$3,500,000.00
$4,000,000.00
FY 2013 - Division Medical
Services
FY 2014 FY 2015 FY2016 FY2017
5 Year Analysis of Medicaid Recoupments and Claims
$2.1 million$1.1 million$3.8 million$2.7 million$3 million
2017 OMIG Initiatives
Behavioral Health (Group Psychotherapy) OMIG recommendations• reduction to 4 daily units ( 1 hour) and 100 units per year passed
• work with DBHS/Beacon on Authorization for 911 and child population
• $14.5M reduction in Group Psych since October 2016 implementation
• Rate reduction from $13.80/unit to $10.00 withdrawn as compromise for BH Transformation reduction
could have been much higher. Have requested DHS review whether this reduction could be revisited.
Personal Care and Home Health Reform• August 3, 2016 – OMIG asked DHS & DMS to join in reform initiative and to assign all workers ID #
• Reform will help protect vulnerable population and reduce fraud, waste, and abuse.
• Other states like Alaska and Minnesota have realized significant savings to Medicaid programs.
• Recommendations to DHS/DMS for reform that could save millions each year
• Recommendations could provider better oversight, treatment, care, and protection
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2017 OMIG Initiatives
• Vision recommendations and reform
• Dental reviews and education
• Pharmacy recoveries and reform
• Hospital In-patient reviews
• School based therapy initiatives
• Dual Eligible Recipient recoveries and reviews
• Emergency and Non-Emergency transportation
2017 OMIG Initiatives• Behavioral Health Reform
• Transportation
• Vision, Dental & Pharmacy
• In-patient Hospital Stays
• School-Based Therapy
• Dual Eligible Recipients Payments
• Personal Care and Home Health Reform
• Medicaid Expansion Enrollment (Arkansas Works FFM)
Total Cost Savings Impact = $30 million
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CLAIMS % Increase Collections % increase
TOTALS: $3,791,902.58 28.44% $2,815,711.54 57.11%
OMIG Recoupments/Reversals/Claims and Collections
Agency spend
Total Agency Budget $2.68 million
Total Agency expenditures $2.35 million
“Turn Back” $330,000 (12.3%
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Extrapolation
The department shall not rely on the denial of one claim as
the sole basis for the denial of a subsequent claim and
shall establish that the subsequent claim is deficient.
Ark. Code Ann. §20-77-1703(f)
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Data Analytics leads to Investigations
“As a provider, you are required to retain and
make records available . . .”
“Please compile and provide legible copies of
all the original patient records . . .”
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Data Analytics for Dodd• Date trends showed continued and excessive
billing even with fewer recipients being
provided services
Billing Cycle Patients Payments Avg. $$ per Patient
Jan-14 24 $ 24,260.32 $ 1,010.85
Mar-14 20 $ 20,924.24 $ 1,046.21
May-14 18 $ 18,336.96 $ 1,018.72
Jul-14 18 $ 27,459.18 $ 1,525.51
Sep-14 21 $ 40,443.90 $ 1,925.90
Nov-14 19 $ 34,618.25 $ 1,822.01
Jan-15 14 $ 21,151.72 $ 1,510.83
Mar-15 12 $ 24,061.16 $ 2,005.10
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What is your duty as an Accountant?
• Duty
– Ethical vs. Legal?
• Has your client/company evaded taxes?
• Is your client/company attempting to evade
taxes?
• What do you do? / Who do you contact?
• What is your exposure?
CPA Indictment
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Potential Criminal Exposure
The IRS also accepts complaints about tax return preparers who have committed fraud, and anyone with an issue may submit a complaint using Form 14157, Complaint: Tax Return Preparer. In-house accountants who cook the books or purposefully include erroneous data in their company's tax returns or accounting documents are responsible for misconduct and may even be criminally liable.
AccountantResponsibility http://www.investopedia.com/terms/a/accountant-esponsibility.asp#ixzz4oiYevki7