Indiana Medicaid Recovery Audit Contractor Program

1. Indiana Medicaid Recovery Audit Contractor Program Indiana Rural Health Association Spring Into Quality March 2, 2012

2. Medicaid RAC Overview • As a requirement of the 2010 Patient Protection and Affordable Care Act (PPACA), the Centers for Medicare and Medicaid Services (CMS) established the Medicaid Recovery Audit Contractor (RAC) program as a measure for states to promote the integrity of the Medicaid program. • Launch required by January 2012. • Medicaid RACs will review claims submitted by providers of items and services or other individuals furnishing items and services, for which payment has been made under section 1902(a) of the Social Security Act or under any waiver of the state plan, to identify underpayments and overpayments and recoup overpayments for the states. (42 CFR 455.506(a))

3. Medicaid RAC Improvements The final rule (42 CFR 455, Subpart F) includes a number of provisions that respond to key American Medical Association (AMA) concerns stemming from Medicare RAC behaviors: • Rules and guidelines • Medicaid RACs are limited to a three-year look-back period. • Medicaid RACs are required to notify providers of overpayment findings within 60 days. • Medicaid RACS must identify and report underpayments. • Coordination to eliminate duplication • Medicaid RACs must coordinate their RAC efforts with other audit programs. • Medicaid RACs are prohibited from auditing claims that they or others have already audited. • Improved communication during audit • Medicaid RACs must employ trained medical professionals and at least one medical director to review medical claims. • States are required to set limits on medical record requests.

4. Partnership in Program Integrity: Fraud and Abuse Detection System (FADS) The Indiana Office of Medicaid Policy and Planning(OMPP) established a strong partnership with Thomson Reuters, an innovative Fraud and Abuse Detection System (FADS) contractor, who can deliver the combination of technology, expert consulting, and auditing services necessary to expand program integrity efforts in Indiana.

5. Partnership in Program Integrity:Fraud and Abuse Detection System (FADS) • Thomson Reuters, in collaboration with other vendors, is managing this comprehensive program integrity solution. • Data analysis, data mining, algorithms • Surveillance and Utilization Review Systems (SURS) • Draft audit findings • Requests for self audits • Desk audits, field audits • Coordination and support: Office of the Inspector General (OIG), Medicaid Fraud Control Unit (MFCU), Medicaid Integrity Contractor (MIC) audits

6. Indiana Medicaid RAC Program Thomson Reuters, as the Indiana FADS contractor, is coordinating the RAC program for OMPP through a subcontract with HMS.

7. Indiana Medicaid RAC Program • Thomson Reuters Roles and Responsibilities • Oversee the RAC audit process, including: • Data mining and algorithm development, and • Audit, final resolution, and collection of overpayments. • Oversee quality assurance. • Work with OMPP to: • Determine the best way to deploy the RAC to achieve optimum program integrity results for the State of Indiana. • Develop and maintain a process to approve provider outreach and education programs.

8. Indiana Medicaid RAC Program • FSSA and OMPP Roles and Responsibilities • Research policy and determine strategic direction for Medicaid RAC audits. • Provide final approval of the type of audits the RAC will deploy for each provider and/or audit project. • Prior to the launch of audits requiring medical records review, FSSA and OMPP will set limits for medical record requests.

9. Indiana Medicaid RAC Program • HMS Roles and Responsibilities • Perform data mining, claims analysis, and data analysis to identify: • Overpayment and underpayments, • Provider billing errors, and • Providers for automated and complex reviews, including medical and • financial records, patient accounting systems and various financial • documents. • Coordinate with OMPP, Thomson Reuters, and others as necessary. • Report fraud and patients at risk within one business day to OMPP. • Provide and staff a toll free customer service line for providers audited • by HMS.

10. HMS RAC Workplan • Aligns with federal guidelines • Four components • Credit balance audits • Automated reviews • Complex reviews • Identify underpayments and recoup identified overpayments • Approach • Fee-for-service claims only (managed care is currently excluded) • Understand OMPP’s data, payment issues, and providers. • Apply specific coverage, billing, coding, clinical, and payment policies in place on the date of service. • Educate providers to prevent or reduce future overpayments.

11. HMS RAC Highlights • Available Resources • Utilize existing data feeds. • Provide expert data analysis, algorithm development, and data processing capabilities. • Healthcare Expertise • Conducts accurate and efficient validation of inappropriate payments. • Uses standard record request, recovery, and appeal support processes that emphasize customer service and minimize provider abrasion. • Focuses on ongoing, iterative improvement to stay ahead of improper payments.

12. HMS RAC Highlights (cont’d) • Transparency and minimal provider abrasion • Verifies provider addresses and confirms provider audit contact. • Minimizes medical record requests. • Provides detailed rationale/notice of audit letters. • Compiles detailed improper payment scenarios. • Solid clinical foundation • Medical Director and 600-physician panel • Indiana-licensed physicians • Nurse reviewers and clinical coding specialists • Physician approved internal review guidelines • Case tracking and web-based applications

13. RAC Process Overview Transparency/ Collaboration with OMPP/Others

14. Initial Areas for Review • Credit balance audits • Perform onsite and desk reviews. • Focus on hospitals. • Review provider disclosed accounts to determine overpayments. • Scenario development • OMPP, Thomson Reuters, and HMS to collaborate on data mining targets. • Research Indiana specific policy and regulations. • Conduct pilot data mining based on research. • Document scenario and obtain OMPP approval.

15. Automated Reviews • Improper payments can be identified clearly and • unambiguously from claim data elements and well • established policy and rules. • Complex review of documentation is not required to validate that an improper payment exists. • Examples: • Duplicate payments/charges • Clear unit billing error • Unbundling • Correct coding

16. Complex Reviews • Data mining/analysis identifies a potential improper payment that • cannot be automatically validated. • Claims are flagged for further review and documentation is required • to determine if an improper payment exists and/or the amount of the • improper payment. • Documentation is requested from the provider or appropriate party • and reviewed to determine if an improper payment exists. On-site • audit/review may also be required. • Examples: • Diagnosis-related grouping (DRG) billing • Balance billing • Excess unit billing • Coding abuse

17. RAC Reconsideration and Appeals • Providers have an opportunity for reconsideration of findings, based on submission of records, and a right to appeal for automated and complex reviews. • AdministrativeReconsideration: • Providers must request administrative consideration within 45 days of receiving Draft Audit Findings, or they lose their right to appeal a final calculation of overpayment.[See IC 12-15-13-3.5(c).] • Appellate procedure following reconsideration and receipt of Final Calculation of Overpayment: • 45 days to file Statement of Issues. [See 405 IAC 1-1.5-2(d) & (e).] • 60 days to file Administrative Appeal. [See IC 12-15-13-3.5(e)(2).]

18. Questions, Concerns, and Contact Information • Contact Information • Mary Diaz-Przybyl, Thomson Reuters, Benefit Integrity Manager mary.diazprzybyl@thomsonreuters.com317-554-4449 • May Rifka, HMS, Program Director, mrifka@hms.com 317-490-1773 • HMS RAC Provider Toll Free Line 855-809-4039 • Jina Hughes, OMPP, Program Integrity Manager jina.hughes@fssa.IN.gov317-234-2129 • SUR Toll Free Provider & Member Concerns Line1-800-457-4515, Option 8 for Audit Issues

19. Questions, Concerns, and Contact Information Only formal responses to questions asked through the www.in.gov/fssa inquiry process will be considered official and valid by the State. No participant shall rely upon, take any action, or make any decision based upon any verbal communication with any State employee or designated contractor, including responses in today’s presentation.

20. www.in.gov/fssa ‘Contact Us’

21. www.in.gov/fssa SCROLL DOWN… Include Attn: Program Integrity Direct to OMPP