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  • 1

    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

    2

     Background and Requirements for Provider Self- Audits

     Examples of Inappropriate Payments Suitable for Provider Self-Audits

     Types of Provider Self-Audits

     VBH-PA Provider Self-Audit Protocol

    VBH-PA Provider Self-Audit Protocol

  • Background and

    Requirements

    for Provider

    Self-Audits

    3VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    4

     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

    VBH-PA Provider Self-Audit Protocol

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

  • Background and Requirements for Provider Self-Audits

    5

     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

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    6

     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

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    7

     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/b ulletin_admin/d_004259.pdf

    VBH-PA Provider Self-Audit Protocol

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

  • Background and Requirements for Provider Self-Audits

    8

     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.

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    9

     Medical Assistance Bulletin 99-02-13

     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.

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    10

     Medical Assistance Bulletin 99-02-13

     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

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    11

     Medical Assistance Bulletin 99-02-13

     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

    VBH-PA Provider Self-Audit Protocol

  • Background and Requirements for Provider Self-Audits

    12

     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/medi calassistanceproviderselfauditprotocol/

    VBH-PA Provider Self-Audit Protocol

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

  • 13

    Examples of

    Inappropriate

    Payments Suitable

    for Provider Self-

    Audits

    VBH-PA Provider Self-Audit Protocol

  • Fraud, Waste, and Abuse

    14

     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

    VBH-PA Provider Self-Audit Protocol

  • Fraud, Waste, and Abuse

    15

     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

    VBH-PA Provider Self-Audit Protocol

  • Fraud, Waste, and Abuse

    16

     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

    VBH-PA Provider Self-Audit Protocol

  • Examples of Inappropriate Payments Suitable for Provider Self-Audits

    17

     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