The Medicaid Integrity Program National Association for Medicaid Program Integrity Williamsburg, Vir

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The Medicaid Integrity Program National
Association for Medicaid Program
IntegrityWilliamsburg, VirginiaAugust 25, 2008

• David Frank, Director
• Paul Miner, Deputy Director
• Medicaid Integrity Group
• Centers for Medicare Medicaid Services

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Deficit Reduction Act of 2005 (DRA)

• ? Section 6034 (42 U.S.C. 1396u-6) created the
  Medicaid Integrity Program. Signed into law in
  February 2006.
• ? Created first national program for combating
  Medicaid provider fraud and abuse.
• ? The Centers for Medicare Medicaid Services
  (CMS), within the Center for Medicaid and State
  Operations, created the Medicaid Integrity Group
  (MIG) to carry out the Medicaid Integrity
  Program.

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Partnership with States

• Medicaid Integrity Programs purpose is to
  support, not supplant, program integrity efforts
  of the States.
• MIG has utilized an Advisory Committee. States
  have participated in this Committee and have
  played a key role in other aspects of the
  Programs development.
• States will continue to be MIGs partners.

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Contracts for the Performanceof Medicaid
Integrity Program

• ? Procure contractors to
• review Medicaid claims to see assess whether
  fraud or waste has occurred or is likely to
  occur
• audit Medicaid claims
• identify overpayments and
• educate Medicaid providers, managed care
  entities, beneficiaries, and others concerning
  payment integrity and quality of care.
• ? These contractors are collectively known as the
  Medicaid Integrity Contractors (MICs).

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Medicaid Integrity Group

• ? Two Main Lines of Business
• Medicaid Integrity Contracting
• Support and Assistance to States

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Organization of the Medicaid Integrity Group

• ? Office of Group Director
• ? Oversees Medicaid Integrity Group
• ? Division of Medicaid Integrity Contracting
  (DMIC)
• ? Oversees procurements, evaluation and
  oversight of MICs.
• ? Division of Fraud Research Detection (DFRD)
• ? Oversees the development of strategies to
  review Medicaid data to assist the MICs and
  States.
• ? Division of Field Operations (DFO)
• ? Approximately 40 field staff in CMS New York,
  Chicago, Atlanta, Dallas, and San Francisco
  offices.
• ? Conducts Medicaid program integrity reviews of
  States.
• ? Provides support, assistance to States
  concerning Medicaid program integrity issues.

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Medicaid Integrity Contractors (MICs)

• ? Review of Providers MICs (Review MICs)
• ? Data-driven approach using Medicaid claims
  data and working with DFRD, Review MICs identify
  high risk areas and potential vulnerabilities
  supply leads to Audit MICs of providers to be
  audited.
• ? In December 2007, CMS awarded umbrella
  contracts to five companies ACS Healthcare
  Analytics AdvanceMed Corporation IMS Government
  Solutions Thomson-Reuters Safeguard Services.
• ? In April 2008, CMS awarded first task order to
  Thomson- Reuters. Task Order covers CMS Regions
  III and IV.
• ? Procurement process continues. Additional task
  orders to be awarded over the next year for other
  CMS regions.

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Audit of Providers MICs (Audit MICs)

• ? Conduct post-payment audits of Medicaid
  providers. Perform combination of field and desk
  audits. Begin with fee-for-service providers and
  cost reports.
• ? To avoid duplication of State efforts, MIG
  will share list of provider audit targets with
  States. If an audit will interfere with State
  and/or law enforcement activities, the audit will
  not occur.
• ? Identify overpayments, but will not be
  involved in the collection of overpayments. Under
  Federal law, CMS collects Federal share from
  States. Under State law, States pursue
  collection of overpayment from providers.
• ? Are not paid based on the number or dollar
  amount of overpayments.

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Audit MICs (contd)

• ? Audit protocols were developed by MIG in
  coordination with MIG Advisory Committee.
  Protocols have been reviewed, validated by
  HHS-Office of Inspector General.
• ? MIG, Audit MICs work closely with States
  throughout audit process.
• ? MIG provides States with opportunities to
  review audit findings before they are finalized.
• ? Audit MICs make referrals to U.S. Department
  of Health Human Services, Office of Inspector
  General, which, in turn, will share referrals
  with State Medicaid Fraud Control Units.

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Audit MICs (contd)

• ? In December 2007, CMS awarded umbrella
  contracts to five contractors Booz Allen
  Hamilton (Booz) Fox Associates Health
  Integrity, LLC Health Management Solutions and
  IPRO.
• ? In April 2007, CMS awarded first task order to
  Booz. Task order covers CMS Regions III and IV.
• ? Procurement process continues. Task orders for
  other CMS regions to be awarded throughout the
  next year.

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Education MICs

• ? Purpose is to educate Medicaid providers,
  beneficiaries, and others on issues of payment
  integrity and quality of care.
• ? Ongoing procurement, with umbrella contracts
  expected to be awarded by autumn 2008.

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Benefits to States of MICs

• Enhance, but do not duplicate, States current PI
  activities.
• Increase the number of provider audits without
  additional strain on State audit staff.
• Increase the universe of collections for States
  by identifying more inappropriate payments.
• Help States improve their payment systems through
  sharing of successful data algorithms, best
  practices, lessons learned.

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Support and Assistance to States

• ? Medicaid Integrity Institute (MII)
• National training facility for State Medicaid
  program integrity employees. Established at
  existing U.S. Department of Justice prosecutor
  training facility. DOJ staff partners with MIG,
  States to design courses for State Medicaid PI
  employees. Goal is to meet State training needs,
  establish credentialing process for State
  Medicaid PI.
• ? Technical Assistance to States
• MIGs DFO communicates with State PI staff to
  answer questions regarding Medicaid PI issues and
  providing various forms of technical assistance.
  DFO also occasionally supplies staff to work on
  Medicaid PI-related special projects.

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Support and Assistance to States(contd)

• ? State Program Integrity Reviews
• DFO conducts periodic reviews of State Medicaid
  program integrity operations. Purpose is to
  identify regulatory non-compliance, program
  vulnerabilities, and best practices.
  Approximately one-third of the States/Territories
  are reviewed each year.

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Questions?

• ? David Frank
• David.Frank_at_cms.hhs.gov
• ? Paul Miner
• Paul.Miner_at_cms.hhs.gov