arkansas medicaid provider annual billing workshop · • reversing claims-creates uncertainty...

Arkansas Medicaid Provider Annual Billing Workshop

Elizabeth SmithInspector General

Mission of OMIG:

To detect and prevent fraud, waste, and abuse within the medical assistance program.

Medicaid Auditors• OMIG (Office of Medicaid Inspector General)• Legislative Audit• DHS (Retrospective Review)

OMIG’s RequirementsProgram Integrity - To prevent, detect, and investigate fraud, waste, and abuse in the Medicaid Program.

Verify whether services reimbursed by Medicaid were properly billed and actually furnished to beneficiaries;

Recover improperly expended funds;

Report fraud and abuse to US HHS;

Refer cases to AG MFCU & law enforcement for criminal prosecution;

Recommend and implement changes in the Medicaid program.

Prevent waste in the program• Identify policies needing revision• Implement changes to Medicaid programs• Medicaid worker identification number• Impact of EVV legislation

OMIG Audit ProcessWho do you audit?• New Providers• Previously Audited Providers• Providers Identified through Data Analytics• Providers Identified by Complaint• Previously Unidentified Providers

OMIG Audit ProcessWhy do you audit?• Fraud Hotline Complaints/Tips• Law Enforcement Referrals• Internal Referrals• Corrective Action Plan Compliance Reviews• Data Analytics

OMIG Data AnalyticsOPTUM – Fraud Detection System• Provider Spike Detection • Peer Review Analysis and Outlier Identification• Algorithms • Claims Risk Analysis

OMIG Audit ProcessField Audit• On-site Review• Conduct Staff and Management Interviews• Audit Scope• OMIG may review claims that are 3 years old• OMIG may review claims that are 5 years old if

fraud is suspected

OMIG Audit ProcessDesk Audit• Off-site Review• OMIG requests records from the provider• The provider must respond to a records request within

14 calendar days• Audit Scope• Identical to field audits

Records RequestAuthority as Program Integrity Function• Arkansas Medicaid Manual • §142.300 - Conditions Related to Record Keeping• MAINTAIN YOUR RECORDS!!!• Enrollment Contract requirement • §151.000 - Grounds for Sanctioning Providers

Subpoena Power and Production of Records• Ark. Code Ann. §20-77-2506

OMIG Audit ProcessPotential Outcomes• No findings• Findings• recoupment

• Observations• Non-monetary

• Area of Concern• MFCU/Law Enforcement Referral• Credible allegation of fraud-requires temporary

suspension; Possible suspension of performer only

Corrective Action Plans

Websitesteps

Self-Reporting & Self-DisclosureDuty of the Medicaid Inspector General is to:• Develop protocols for efficient self-disclosure• Consider a Medicaid Provider’s good faith as a

mitigating factor• Self-Disclosure Protocol on OMIG website• OMIG.Arkansas.gov • Reversing claims-Creates uncertainty regarding

questioned claims

Corrective Action Plans• Read the OMIG Report / Findings• Develop a plan of action addressing

findings, observations, and areas of concern

• Be specific in your steps and procedure• Provide a person/name/position for

accountability

Reagan Cook, RN, CPC, CPMA, CPIPRegistered Nurse Manager323 Center Street, Ste. 1200Little Rock, AR 72201501-537-1668Reagan.cook@omig.arkansas.gov