definition of fraud vs. abuse - home - northeast pharmacy€¦ · maintain sound filing practices...
TRANSCRIPT
![Page 1: Definition of Fraud vs. Abuse - Home - Northeast Pharmacy€¦ · Maintain sound filing practices Conduct your own internal audit of random claims Conduct effective training and education](https://reader033.vdocuments.us/reader033/viewer/2022052023/603915f2b359e2781030ba57/html5/thumbnails/1.jpg)
Samantha Allard OSD Consultant and Project Manager
The Connecticut Department of Social Services in Partnership with the UCONN School of Social Work
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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version 1.3 - 7/6/2017
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At the end of this training participants will have a better understanding of:
The purpose of an audit
The audit process
Preparation for an audit
Common errors found during audit
How to appeal an audit decision
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
TODAY’S GOALS
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
PURPOSE OF AN AUDIT
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Audit is a formal review to ensure that Medicaid payments are:
For covered services that were actually provided, properly billed and documented.
To ensure that claims were paid according to Federal and State laws, regulations, and policies.
DSS Quality Assurance Medicaid Audits are conducted as required by Conn. Gen. Stat. § 17b-99(d)
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U.S.C. – United States Code (federal statutes)
Conn. General Statutes
C.F.R. – Code of Federal Regulations
Regulations of CT State Agencies
Pharmacy Provider Manual
Provider bulletins
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
MEDICAID POLICY
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No- Auditors enforce policy.
During an audit if questions regarding the interpretation of policy arise then the policy division is consulted for clarification.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOES THE AUDIT DEPARTMENT WRITE POLICY?
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YES- The State Medicaid Program is audited by:
DHHS OIG performs audits of the Medicaid federal share.
CMS performs audits as part of the PERM review
State auditors audit the State Medicaid program.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOES THE STATE MEDICAID PROGRAM GET AUDITED?
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Payment for duplicate items
Payment for non-covered services
Payment that should have been paid by a third party
Pricing errors
Data entry errors
Lack of documentation
Insufficient documentation
Number of unit errors
Policy violations
Administrative errors
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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IMPROPER PAYMENT ERRORS
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To determine whether:
Services were rendered to an eligible recipient
Claims properly reflect the services rendered
Original documentation was maintained to accurately evidence the services provided
Claims were submitted in accordance with Department policies, regulations, provider manuals and bulletins
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
OBJECTIVE OF AN AUDIT
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Goal: Establish internal controls to decrease providers’ risk of practices that result in errors.
Review and adhere to standard procedures and regulations outlined in your provider manual and provider enrollment agreement
Maintain sound filing practices
Conduct your own internal audit of random claims
Conduct effective training and education
Maintain open lines of communication with staff
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
COMPLIANCE PROGRAM
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Helps identify and correct documentation and billing issues before submitting claims
Allows for identification and correction of issues before they become a problem
Puts provider in a better position to respond to an audit
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
BENEFITS OF COMPLIANCE PROGRAM
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Adjust claim if overpaid or underpaid
Adjust claim when information on a paid claim is incorrect ie; client ID, NPI, date of service
**Adjustments should not be made to claims that are part of an open audit.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
CLAIM ADJUSTMENTS
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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PHARMACY AUDITS CONDUCTED BY DSS
Provider Selected by DSS
Universe of Claims Forwarded to Statistician
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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AUDIT SAMPLE
Sample Selected Based on Statistically Valid Sampling Methodology
Samples Forwarded to DSS via Secure Server
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Review your audit notification
Have records easily accessible
Have the appropriate personnel available
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
AUDIT PREPARATION
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Audit Location
Onsite Audit – Auditor may go to multiple locations dependent on the selected samples
Once auditor is onsite, the provider will be given a list of claims to be reviewed
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DAY 1 AUDIT
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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Common Error: NPI submitted on the claim to identify the prescriber does not match the NPI on the original hard copy prescription.
Appropriate Procedure: Verify NPI on the claim matches NPI on prescription. NPPES can be used to search for provider NPI.
Exception: Certified pharmacists may use his/her NPI as prescribing provider to dispense naloxone (Narcan)
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
BILLING – PRESCRIBER’S NPI DOES NOT
MATCH THE CLAIM
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Common Error: Primary TPL EOB is not documented or the amount paid on the TPL EOB does not match the amount on the Medicaid claim.
Appropriate Procedure: Maintain TPL EOB for 5 years and submit copy when audited. Verify amount shown as paid by TPL on the EOB is the same as the amount submitted on the Medicaid claim. If they are different submit a corrected claim.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
BILLING - PRIMARY TPL EOB NOT DOCUMENTED OR SUBMITTED INCORRECTLY
ON CLAIM
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE:
*
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Common Error: The quantity dispensed is different then the quantity on the claim.
Appropriate Procedure: If more than one dispensing is needed, ie: due to limited supply, then provide documentation showing the dispensing of the remaining quantity owed.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
BILLING - QUANTITY DISPENSED DOES NOT MATCH QUANTITY ON CLAIM -
PARTIAL FILL
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE:
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Common Error: Days supply indicated on the claim is not correct based on the original prescription. Example: Rx for 5 mls Lumigan indicates 50 day supply; however, the claim submitted indicates 15 day supply. Rx on 12/1/14 and again on 12/14/14 (early refill).
Appropriate Procedure: Verify that the days supply submitted on the claim is the same as on the original prescription.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION – DAYS SUPPLY RESULTING IN AN EARLY REFILL
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - COUNSELING OFFER NOT DOCUMENTED OR INVALID FOR
DATE OF SERVICE
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Common Error: Offer to counsel is not properly documented.
Appropriate Procedure: Provide documentation that supports the offer to counsel was made for all initial and refilled prescriptions.
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Common Errors: “Brand Medically Necessary” was not written on the prescription to substantiate the DAW1 code submitted on the claim.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - DAW1
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Appropriate Procedure: Claims submitted as DAW1 should have:
Paper prescription: “brand medically necessary” in doctor’s handwriting
Electronic prescription: proper DAW1 code
Telephonic prescription: pharmacist must specify “brand medically necessary” or “no substitution” on prescription in his/her handwriting along with the time of authorization and name of person who communicated the authorization, written verification must be received within 10 days.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION - DAW1
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Non-compliant Compliant
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE:
*
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Common Error: Documentation of delivery could not be substantiated.
Appropriate Procedure: Tracking numbers and/or proof of delivery should be available to verify proof of delivery of claims that are delivered or shipped.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION – DELIVERY NOT DOCUMENTED
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Common Error: Diagnosis is required and indicated on the claim submission; however, it is not found on the original hard copy prescription.
Appropriate Procedure: Pharmacist can enter diagnosis on the prescription after verification with the prescriber.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - DIAGNOSIS CODE
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Common Error: Directions on the prescription record concerning dosage and frequency do not match directions on the original prescription.
Appropriate Procedure: Dosage and frequency directions on the prescription match those given to the patient on the prescription record.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - DIRECTIONS DO NOT MATCH PRESCRIPTION SIG
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE:
Prescription
Prescription Record
*
*
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Common Error: NDC is obsolete or terminated. NDC on the claim doesn’t match dosage form or strength on the prescription.
Appropriate Procedure: Verify that a current NDC is being submitted on the claim. When searching by drug name verify that the strength, dosage form and package description of the NDC match what is on the claim.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION/SERVICES – INCORRECT DRUG/NDC
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Common Error: The most cost effective single or combination of strengths was not dispensed. Example: Prevacid dispensed at 90 x 15 mg solutabs; however, the most cost effective (cost per pill) single or combination of strengths are 30 x 15mg and 30 x 30mg Solutabs.
Appropriate Procedure: Ensure that the most cost effective strength is dispensed.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION/SERVICES –
MEDICATION WASTE/OVERPAYMENT
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Common Error: Prescriber’s signature is missing or invalid on a written prescription. Faxed prescriptions with rubber stamp (not handwritten).
Appropriate Procedure: Provider should attain new prescription with a signature or verbally verify with the prescriber.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - PRESCRIBER SIGNATURE MISSING OR INVALID
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Common Error: Prescription is refilled more than authorized based on the refills indicated on the original prescription. Refill is rolled over to a new prescription number without authorization from the prescriber.
Appropriate Procedure: Authorization to refill the prescription must be obtained from the prescriber if all refills have been used.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - REFILLS
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Common Error: Original prescription not supplied.
Appropriate Procedure: Maintain all documentation supporting the claim.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - RX MISSING
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Common Error: Handwritten or computer generated and printed prescription does not contain at least one industry recognized feature from each category:
1) Feature to prevent unauthorized copying of a completed or blank prescription
2) Feature to prevent erasure or modification of information written on the prescription
3) Feature to prevent the use of counterfeit forms
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
DOCUMENTATION - TAMPER RESISTANT
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Appropriate Procedure: If prescription does not meet tamper resistance requirements, then contact the prescribing provider. During audit provide documentation supporting the prescribing provider was contacted to validate the prescription.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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DOCUMENTATION - TAMPER RESISTANT
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Common Error: Quantity dispensed was greater than the quantity ordered.
Appropriate Procedure: Any change in quantity dispensed should have:
Reason for the change
Name of person authorizing the change, verify with prescriber and document call
Pharmacist name or initials and date notated on the hard copy prescription
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
SERVICES - DISPENSING QUANTITY GREATER THAN ON PRESCRIPTION
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Common Error: Quantity dispensed is less than ordered on the prescription.
Appropriate Procedure: Quantity dispensed should match the quantity ordered on the prescription.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
SERVICES - DISPENSING QUANTITY LESS THAN ON PRESCRIPTION
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE:
Prescription
Claim
*
*
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Common Error: Generic is written on the prescription; however, dispensed with a brand medicine that is not on the preferred drug list.
Appropriate Procedure: Dispense generic if it is written on the prescription, unless directed by the Department to fill as brand per preferred drug list.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
SERVICES - GENERIC WRITTEN FILLED BRAND NOT ON PDL
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Common Error: Prescription, or refills, dispensed after 12 months from the date written by the prescriber. (6 months prior to 8/1/15) *Does not apply to items under the Controlled Substance Act which are allowed 5 refills or up to 6 months whichever comes first.
Appropriate Procedure: If prescription or refill is requested beyond the 12 month date of issuance then a new prescription should be requested.
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
SERVICES - PRESCRIPTION FILLED GREATER THAN TWELVE MONTHS FROM THE DATE
WRITTEN
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Outstanding Documentation List Given to Provider
Provider has opportunity to submit missing documentation
Errors are Reported to Statistician
Statistician Calculates Extrapolation
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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CLAIM REVIEW COMPLETE
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As provided under statute 17b-99(d) examples of errors that may not be extrapolated:
Payment or billing errors resulting from the transition to a new payment, billing or accounting system
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
EXTRAPOLATION
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Statutory extrapolation threshold = 1 ¾% of total claims paid for the audit period
If extrapolated error amount exceeds the statutory extrapolation threshold, then financial overpayment is the extrapolated error amount
If extrapolated error amount does not exceed the statutory extrapolation threshold, then financial overpayment is the sample error amount
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
STATUTORY EXTRAPOLATION THRESHOLD
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Overpayment Due = Extrapolated Amount
Overpayment Due = Sample Errors
Total claims for audit
period $100,000 $500,000
% applied to total paid
claims 1.75% 1.75%
Calculated
extrapolation
threshold
$5000 > $1,750 $5000 < $8,750
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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EXAMPLE: EXTRAPOLATED ERROR AMOUNT =$5000
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Written request for hearing
No later than 30 days after final report received
Request must contain detailed description of each specific item of aggrievement
Final decision based on hearing
Appeal of final decision to Connecticut Superior Court
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
APPEAL PROCESS
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DSS Website – Audit Protocols www.ct.gov/dss
HMS – status of TPL 866-277-4271
DXC Provider Assistance Center 800-842-8440
Pharmacy Prior Authorization Assistance Center 866-409-8386
DSS Map www.ctdssmap.com
Provider Manuals (Enrollment & Re-enrollment, policy, claim submission instructions)
Bulletins (Can search by provider type)
Pharmacy Information Section
Preferred Drug List
Pharmacy Program Publications
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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IMPORTANT DSS RESOURCES
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Dept. of Consumer Protection – Drug Laws and Regulations www.ct.gov/dcp/cwp/view.asp?a=1620&Q=275966&PM=1
U.S. Dept. of Justice – DEA www.deadiversion.usdoj.gov/index.html
State of CT Statute www.cga.ct.gov/lco/statutes.asp
State of CT Regulations https://eregulations.ct.gov/eRegsPortal/
Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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IMPORTANT REGULATION RESOURCES
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Prepared by the CT DSS Office of Organizational and Skill Development in partnership with the UCONN SSW
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