Medicaid Compliance

Risk Area Standards of ConductTraining for all Com munity Health Plan Employees

Community Health Plan

Agenda...

❚ What is compliance?

❚ Why is it important?

❚ What is a compliance program ?

❚ Risk area standards of conduct

❚ Key federal laws and regulations

❚ Q&A’s

Compliance: Defined...

❚ Compliance n., Conformity in fulfilling official requirements.

❚ Compliance can be described as conducting a business and oneself in an ethical, moral, and legal manner.

Compliance and You...

❚ It’s a matter of who you are, not just something you do.

❚ A matter of character and integrity.

❚ An aspect of quality improvement.

❚ An insurance investment.

❚ IT’S THE RIGHT THING TO DO!!

Why Compliance?

❚ Government, insurance companies and consumers are aggressively reviewing billings, medical results and related processes throughout the healthcare industry.

❚ Major government initiative as they combat fraud and abuse.

❚ Government has authority to question and investigate suspected violations when Federal funds are paid to an organization.

Why compliance?

❚ Government has no tolerance for fraud and abuse.

❚ Government intends to change conduct.

❚ For the Medicaid product (Salud!), we are required to have an effective fraud & abuse detection and prevention program in place.

❙ We are also required to report fraud & abuse to the State.

Why Compliance?

❚ Lack of compliance can lead to investigations.

❚ Individual employees can be questioned during an investigation or subpoenaed to testify in court.

❚ If fraud & abuse is discovered, civil and criminal monetary penalties can be assessed.

Benefits of a Compliance Program

❚ Demonstrate CHP’sstrong commitment to honest and responsible corporate conduct.

❚ Provide guidance to employees regarding appropriate behavior as it relates to fraud and abuse.

❚ Identify and prevent criminal and unethical conduct.

❚ Improve the quality, efficiency and consistency of services.

❚ Create a centralized source for distributing information on health care statutes and regulations.

❚ Encourage employees to report potential problems.

❚ Develop procedures that allow the prompt, thorough investigation of alleged misconduct by corporate officers, management, and employees.

❚ Initiate appropriate, and decisive corrective action.

Benefits of a Compliance Program (cont.)

Benefits of a Compliance Program (cont.)

❚ Through early detection and reporting, losses to the government for false claims can be minimized, and the exposure to civil damages and penalties, criminal sanctions, and administrative remedies reduced.

❚ Overall, an effective compliance program can enhance the efficiency & effectiveness of the organization, and significantly reduce the probability of unlawful or improper conduct.

Major Fraud Settlements

❚ Humana Inc., agrees to pay $14.5 million forinaccuratingreporting their members as dually eligible for both Medicare & Medicaid.

❚ MCO marketing rep. convicted for submitting fraudulent enrollment information to the State for ineligible individuals to the Medicaid program.

Major Fraud Settlements

❚ MCO repaid $1.8 million for fictitious persons enrolled into the Medicaid program. Four MCO employees convicted for submitting names with a mailing address of a homeless shelter.

What is a Compliance Program?

❚ 1. Standards of Conduct & Written Policies and Procedures

❙ CHP will not engage in undesirable practices when obtaining/maintaining a contract with the federal government.

❙ CHP will not engage in fraudulent marketing & enrollment activities.

❙ CHP will not engage in activities to withhold or delay medically necessary health care services.

What is a Compliance Program?(cont.)

❙ CHP will not engage in fraudulent claims submission & billing practices.

❙ CHP will not knowingly engage in activities that would result infalse, inaccurate, untimely and/or incomplete data to HCFA.

❙ CHP will not knowingly and willfully offer, pay, solicit or receive payment to induce the referral of business.

❚ 2. Designation of a Compliance Officer and Committee

What is a Compliance Program?(cont.)

❚ 3. Effective Training and Education

❚ 4. Effective Lines of Communication

❚ 5. Well Publicized Disciplinary Guidelines

❚ 6. Internal Auditing and Monitoring

❚ 7. Promptly Responding to Detected Offenses, Reporting of Identified Issues and Corrective Action

Risk Area Standards of Conduct

❚ A set of standards that clearly delineates policies with regard to fraud, waste and abuse.

❚ Provides guidance to employees on high risk areas in the managed care industry.

❚ Compliance Standards of Conduct are made available to all employees and regularly updated and/or modified.

Risk Area Standards of Conduct

❚ Every Employee:

❙ Shares the responsibility for adhering to all Federal & State laws and statutes.

❙ Is responsible and accountable for complying with the policies and procedures with regard to fraud, waste and abuse and all local, state, and federal statutes and regulations.

Risk Area Standards of Conduct

❚ Violations of laws and regulations can have severe consequences.

❚ Non-compliance with Standards of Conduct may be grounds for disciplinary action, up to and including termination.

Risk Area Standards of Conduct #1-

❚ CHP will not engage in the following practices when obtaining or maintaining a contract with the government:

• Falsification of health care provider credentials.• Falsified or inadequate provider network.• Fraudulent subcontract. This occurs when a subcontract contains misleading information (i.e., pre-dated, post-dated, forged signature or signature without authority).

• Participate in collaborating with competing providers on settingminimum fees and capitation rates.

Risk Area Standards of Conduct #2-

❚ CHP will not engage in the following fraudulent marketing and enrollment activities:

• Misrepresentation to Medicaid beneficiaries (also known as “Slamming”). This involves misleading the prospective enrollee into believing the employee works for the federal program.

• Knowingly distributing marketing materials which misrepresents or falsifies plan information.

• Enrolling nonexistent individuals or ineligible family members.

cont...

Risk Area Standards of Conduct #2-

• “Cherry-picking” or selecting the healthiest segment of the enrollment population. Subtle forms of cherry-picking include:

• misuse of health needs questionnaires.• discouraging prospective enrollees with potentially high utilization needs from enrolling.

• holding health fairs or enrollment meetings on upper floors with no elevators to discourage or preclude disabled persons from attending.

• CHERRY-PICKING IS A MAIN FOCUS OF THE GOVERNMENT!

cont...

Risk Area Standards of Conduct #2-

• Disenrolling undesirable or costly members.• Failing to notify the State of deceased members.

Risk Area Standards of Conduct #3-

❚ CHP will not engage in activities to withhold or delay medicallynecessary health care services, also known as underutilization. These include:

• Untimely assignment of a primary care physician.

• Delay in reassigning a PCP upon a member’s request.

• Discouragement of treatment using geographic or time barriers.

• Failure to serve individuals with cultural or language barriers.

• Failure to provide education services to certain member populations or certain lines of business.

cont...

Risk Area Standards of Conduct #3-

• Failure to provide outreach and follow-up care or federally-required referrals.

• Failure to provide court-ordered treatment.• Failure to provide Medicaid members comparable services such as those provided to commercial or fee-for-service members.

• Defining “appropriateness of care” and/or “experimental procedures” in a manner inconsistent with standards of care.

• Requiring prior authorization for emergency services and denying claims based on the “prudent layperson standard.”

cont...

Risk Area Standards of Conduct #3-

• Ineffective member appeal and grievance process, and burdensome appeal process for providers.

• Unreasonable prior authorization requirements.• Interference with health care professionals’ advice to members. Known as the “gag rule,” this prohibition extends to advice regarding the patient’s health status, medical care, treatment options, risks, benefits and consequences of treatment, or refusal of treatment.

• Incentives to PCPs and specialty providers to illegally limit services or referrals, or inappropriate physician incentive plans.

Risk Area Standards of Conduct #4-

❚ CHP will not engage in fraudulent claims submission and billing practices. These include:

• Routine denial of claims (i.e., emergency, urgent, OOA).• Balance billing members inappropriately.• Double-billing for the same service and keeping the money. This also includes mischaracterizing Medicare-Medicaid dualeligibles.

• Improper Coding (documentation supports a different level of code and unbundling).

• Member fraud and abuse (i.e., inappropriate utilization of services, or lending an enrollment card to an ineligible person).

Risk Area Standards of Conduct #5-

❚ CHP will not knowingly engage in activities that would result infalse, inaccurate, untimely and/or incomplete data submitted to

HCFA.

• These include enrollment,disenrollment, encounter, and claims data.

• The knowing submission of false information to HCFA can lead to criminal or civil penalties.

Risk Area Standards of Conduct #6-

❚ CHP will not knowingly and willfully offer, pay, solicit or receive payment to induce the referral of business reimbursable under a Federal health care program.

• Employees will not offer or provide gifts, free services, or other incentives to prospective enrollees, relatives of prospective enrollees, physicians, hospitals, contractors, assisted living facilities, or other potential referral sources.

Compliance as an Element of Performance

❚ Incorporate Compliance as an element of job performance.

❚ Employees should be up to date on policies and legal requirements that apply to their position.

❚ Failure to do these things can result in:❙ Disciplinary Action

❙ Termination

Other Components of the Compliance Plan

❚ Fraud Information❙ Medicaid Fraud & Abuse National Guidelines for Medicaid Managed Care.

❙ The OIG is at www.dhhs.gov/progorg/oig

❙ HCFA is at www.hcfa.gov

Key Federal Laws & Regulations: False Claims Laws

❙ Billing for services not rendered.

❙ Billing for tests not performed.

❙ Improper diagnosis and coding

❙ Submitting false information.

❙ Duplicate billing.

❙ Medicare secondary payer requirements.

❙ Unbundling.

Key Federal Laws & Regulations: False Claims Laws (cont.)

❙ Submitting false/improper encounter data.

❙ Submitting false enrollment/disenrollmentinformation.

Key Federal Laws & Regulations: Penalties for False Claims

❚ Criminal prosecution.

❚ Civil proceeding.

❚ Sanctions, fines up to $11,000 per claim, treble damages, imprisonment, exclusion from federal programs.

Key Federal Laws & RegulationsCivil Monetary Penalty Laws

❚ These laws are established to impose money penalties against persons/organizations for making false or improper claims or requests for payment.

❚ Up to $25,000 or imprisonment for 5 years or both for falsification of documentation.

❚ Suspension from participating in the Medicaid Programs (program exclusion).

Employee Reporting Obligations

❚ All employees are responsible for reporting any suspected or actual wrongdoing (regardless of whether or not based on personal knowledge).

❚ Report information to a manager, Compliance Officer, or CHP Fraud & Abuse Incident Coordinator.

❚ All reports will be kept confidential to the extent reasonably possible.

❚ Under no circumstance will reporting of any information be taken against any employee.

Open Door Policy and Hotline

❚ Compliance Officer❙ Officer Name & Phone Number

❙ Compliance Line -1-800-888-8888

❚ CHP Fraud & Abuse Incident Coordinator❙ Name & Phone Number