CMS Medicaid Integrity Program

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CMS MedicaidIntegrity Program
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Agenda

• Overview of Medicaid Integrity Program
• Medicaid Integrity Group
• Task Orders
• Program Specifics
• Questions/Discussion

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Overview of Medicaid Integrity Program

• Established via the Deficit Reduction Act of 2005
  (DRA) Section 6034, signed into law February 8,
  2006
• Directs HHS to enter into contracts to carry out
  programs activities, including
• Review of actions of individuals or entities
  furnishing items for services for which Medicaid
  payments were made
• Audit of claims for payment for items or services
  rendered for which a Medicaid payment was made
• Education of service providers, managed care
  entities and beneficiaries

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Overview of Medicaid Integrity Program

• Medicaid Integrity Group (MIG) established under
  the CMSO
• Substantially increased funding dedicated to
  Medicaid program integrity efforts
• Provided 255M in mandatory MIP funding (not
  subject to annual appropriations) over 5 years
• 75M per year after five years
• Additional 25M annually to HHS OIG

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Overview of Medicaid Integrity Program

• Required CMS to hire 100 new employees to help
  protect Medicaid program integrity by providing
  effective support and assistance to states to
  combat provider fraud and abuse
• 79 FTEs to MIG
• 21 FTEs to PERM/Medi-Medi Group
• Gave CMS authority hire contractors to help deal
  with Medicaid fraud and abuse
• Required CMS to develop Comprehensive Medicaid
  Program Integrity Plan (CMIP) every five years
  and to report on the programs effectiveness
  annually

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Overview of Medicaid Integrity Program

• Calls MIP the first national strategy to detect
  and prevent fraud and abuse in the programs
  history
• Outlines four key principles for carrying out MIP
• National leadership
• Accountability for the program integrity
  activities of CMS and its contractors
• Collaboration with internal/external partners and
  stakeholders
• Flexibility to deal with the changing nature of
  Medicaid fraud
• Efforts will yield significant savings to help
  sustain the program

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Overview of Medicaid Integrity Program
Other DRA Provisions Include

• National expansion of Medi/Medi program
• 180M in funding over five years12M in FY06 up
  to 60M in FY11
• Creates incentives for states to enact FCA laws
  by allocating a larger share of recoveries from
  false claims cases to states

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Medicaid Integrity Group (MIG)

• Office of Group Director
• Oversees activities of the MIG
• Division of Medicaid Integrity Contracting
• Oversees procurements, evaluation and oversight
  of MICs
• Division of Fraud Research and Detection
• Identifies fraud patterns/trends, reports
  information to MICs and States
• Division of Field Operations
• Approx. 40 field staff located in NYC, Chicago,
  Atlanta, Dallas, and San Francisco
• Conducts PI review of States
• Provides support and assistance to States related
  to PI matters

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Medicaid Integrity Contractors (MICs)

• Three types
• Review of Provider MICWorking with Division of
  Fraud Research and Detection, uses Medicaid
  claims data to identify potentially fraudulent
  claims and supply leads to Audit MIC
• Audit MICConduct desk and field audits, identify
  overpayments, fraud referrals. Not involved in
  collection of overpayments
• Education MICEducation of service providers,
  managed care entities, beneficiaries, and other
  individuals w/r/t program integrity and benefit
  quality assurance issues
• Review of Provider and Audit MICs umbrella
  contracts (five each) were awarded in December of
  2007
• Umbrella contracts allow MICs to bid on
  individual task orders

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MIC Jurisdictions/Regional Offices
Chicago Regions 5,7
San Francisco Regions 9,10
Also CNMI, Guam, American Samoa
New York Regions 1,2
Atlanta Regions 3,4
Dallas Regions 6,8
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Audit MIC Contractors

• Health Management Systems, Inc., New York, NY
• Booz Allen Hamilton Inc, Rockville, MD(awarded
  Task Order 0001)
• Fox Systems, Inc., Scottsdale, AZ
• Health Integrity, LLC, Easton, MD
• Island Peer Review Organization, Lake Success, NY

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Review of Provider Contractors

• Safeguard Services, LLC, Plano, TX
• IMS Government Solutions, Falls Church, VA
• AdvanceMed Corp, Rockville, MD
• division of CSC, Inc.
• The Medstat Group, Inc., Ann Arbor, MI
• division of Thomson Healthcare
• ACS Healthcare Analytics, Washington DC
• division of ACS, Inc.

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Task Order 0001

• Awarded in April 2008
• Audit MIC Awarded to Booze Allen Hamilton
• Review of Provider MIC Awarded to AdvanceMed

States include Pennsylvania Maryland Delaware Was
hington DC Virginia West Virginia North Carolina
South Carolina Georgia Alabama Mississippi Tenness
ee Florida Kentucky
Approximately 10,000 audits projected
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Task Order 0002
Awarded to HMS in September 2008
States include Texas New Mexico Oklahoma Arkansas
Louisiana
Colorado Utah North Dakota South
Dakota Wyoming Montana
Approximately 2,500 to 10,000 audits depending
on award level
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Program Specifics

• MIC are to enter Joint Operating Agreements with
  States to clearly define respective roles and
  responsibilities of contractors and third
  parties.
• Audit MIC contractor receives leads from
  CMS/Review of Provider MIC
• CMS to ensure that no ongoing investigations are
  underway for audit targets
• Audit MIC contractors make referrals of potential
  fraud to OIG and CMS simultaneously using CMS
  provided form
• CMS developing case management system for
  contractors to utilize for managing audit
  activity

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Program Specifics

• CMS developed detailed Audit Protocols for Audit
  MICs to utilize when conducting audits
• Includes CMS, state, and provider notification
  instructions and templates
• Audits will cover all FFS providers no managed
  care/encounter data auditing in the initial
  period
• Audit targets include

Physicians/ Practitioners Home Health/Skilled
Nursing Hospice Hospital Nursing Facility/
Nursing Home
Renal Dialysis DME Transportation/
Ambulance Labs/ X-ray Pharmacy
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Program Specifics

• Audit types include

Focused Desk vast majority Focused
Field Comprehensive Cost Report

• The MIC will initiate and conduct audit per GAGAS
• Audit results will be shared with states for
  input before final notice to providers
• The MIC is to assist states in overpayment
  recovery, including necessary resources for state
  level appeal

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Questions?