Transcript will begin in October 2011

OMIG\HMS
Integrated Reviews & Provider Portal
Cerebral Palsy Associations of New York State
April 2011
Today’s Objectives
• Describe OMIG’s new approach to payment
recapture
• Demonstrate how this approach can help
optimize recoveries and minimize abrasion
• Provide an overview of the OMIG/HMS Provider
Portal
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Where We Are Now
TPL
Data matching
Cost avoidance
Third party
reviews
Estate and
casualty recovery
Direct billing
PI
Provider self-disclosure
Onsite and desk reviews
Credit balance reviews
Data mining
Long-term care review
Institutional reviews
Disallowances
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Where We Are Headed
INTEGRATION
Provider disclosure
Cost avoidance
Payment integrity reviews
e-Reviews
Data matching
Third party reviews
Estate and
casualty recovery
Data mining
Institutional reviews
Fraud referrals
Disallowances
Onsite and
desk reviews
Long-term care reviews
Direct billing
Free standing clinic reviews
Provider scoring
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ACA Increases Focus on Program
• Section 6402(a) of Affordable Care Act (ACA)
requires providers to “report and return”
overpayments
• Section 6411(a) requires states to establish
contract(s) with one or more Medicaid Recovery
Audit Contractors
• Funding to combat fraud, waste and abuse
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NY Medicaid RAC Program
• OMIG has designated HMS as the New York
Medicaid RAC with CMS’s approval of the SPA
• Integrated approach shares data across
programs
– Maximize identification of payment issues
– Reduce future overpayments
– Minimize provider burden
• The “integrated approach” will be a central
piece to New York OMIG Medicaid RAC
Program
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Integrated Approach
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Integrated Approach
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Integrated Approach
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Integrated Approach
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Integrated Approach
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e-Reviews and Data Mining
• Uses paid claims data from third party
payors and other external data
– Commercial
– Medicare
– Provider A/R (Credit & Debit Balances)
• Allows for validation of overpayment at
time of data mining
• Notifies providers via mail and portal
• Recoveries may be initiated electronically
through MMIS
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e-Reviews and Data Mining (cont.)
• More emphasis on provider compliance
and program oversight
• Each overpayment is reviewed at the
claim level
• Drives the integration of TPL and PI
through data mining
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Integrated Approach
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Integrated Approach
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Integrated Approach
Sentinel Effect = Improved Provider Billing
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Question:
How are we going to work with the
providers to help consolidate and
streamline review distribution,
reconciliation and recovery processing?
Answer:
OMIG/HMS Provider Portal
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Overview of the Provider Portal
• The Provider Portal is a web-based application that will
allow providers a single point of entry for multiple OMIG
reviews
• The provider portal is designed to accommodate
multiple functionalities
–
–
–
–
Third Party Reviews
Payment Integrity Reviews
Provider Self-Disclosures
Medicaid Credit Balance Reporting
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Accessing The Provider Portal
Web-based with 128-bit
security encryption
Login for existing users and
requesting a user account
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New User Registration
Select Registration Type to
pull up the appropriate
registration form
Once the registration form
has been submitted the new
user will contacted by HMS to
verify information
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First Time Access
Enter a new personalized
password and confirm
Enter the Current Password
given to the provider by HMS
during the registration process
Select security
questions and answers
Click OK
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Home Page
Select Application/Project
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Third Party Reviews
Each Third Party Review is assigned a “cycle number”.
“Cycle Search” allows the user to search for a specific review.
Once you have selected the
appropriate Third Party Review
click to open
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Third Party Reviews (cont)
“Recipient Search” function allows the user to pull up all the claims that
appeared on Third Party Reviews that belong to a specific patient
Click to view claim detail
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Third Party Reviews (cont)
“Claim Search” function allows the user to pull up a specific claim that
appeared on a Third Party Review
Click to view claim detail
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Responding to Third Party Reviews (cont)
Information identifying
cycle number, recipient,
and third party coverage
Claim
Information
Click on the down arrow of
“Provider Action/Reasons”
to select the appropriate
Action/Reasons code
Enter comments regarding
the claim in the “Provider
Comments” box
Click “Ok” to save the
Action/Reasons code and
Provider Comments or click
“Cancel” to discard
changes and exit.
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Payment Integrity Reviews
• Types of Payment Integrity Reviews
– Automated Reviews (e-Reviews)
• Consists of overpayments that can identified with extremely
high accuracy
• Provider will be given 30 days to review findings
– Complex Reviews
• Potential overpayments where additional information is
required to make a clear determination
• Providers required to submit documentation to HMS
• HMS reviews the documentation and makes a determination
• Reviews will be sent to providers in a similar fashion as TPR
– Target overpayments through data mining
– Upload targets to the Portal and notify providers
– Providers given clear instructions on how to satisfy each type of
review
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Self-Disclosures
Upon logging into the
provider, users with
appropriate will see the SelfDisclosure application listed
on their home page.
Click “Select” to access the
application.
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Self-Disclosures – Input
Enter basic
claim
information
needed to
identify the
claim
Enter
recipient’s
information
Enter primary
payor and
payment
information
(if applicable)
Enter refund
amount and
reason(s) for
overpayment
Click “Submit” to submit the report to the
“Supervisor” for final review
As refunds
are entered
and saved,
they appear
at the
bottom of
the screen
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Self-Disclosures – Search
Each user is allowed to query for refunds
they entered and/or submitted.
Users with “Supervisor” access will be able
to query all refund entries for the given
provider/facility.
Query options.
Enter the
search criteria
and click
“Search”
Search results are returned at
the bottom of the page
Click “Details” to view
full information on file
Click “Export” to export
search results to an Excel
spreadsheet
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Self-Disclosures – Attestation
Only the users with “Supervisor” access will be able to formally submit selfdisclosures to OMIG-HMS. When submitting the final report, the “Supervisor” will
be asked to attest to the information being submitted.
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Medicaid Credit Balance
Reporting
• Batch Reporting
– Will give providers the ability to upload completed
worksheets with proper attestation, eliminating claim
by claim data entry and reporting
– Supply a report template for providers to use
– May require providers who chose to use batch
reporting to under-go acceptance testing to verify
correct formatting, accuracy of data, etc.
• Will mirror OMIG initiative to prompt self-disclosures
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What to Watch for in 2011
• Third Party Reviews
– Outreach underway to re-register providers to the OMIG-HMS Portal
– Anticipate uploading the first Review to the portal around March 21th
• Self-Disclosures
–
–
–
–
Development completed
Currently in the User Acceptance Testing (UAT) Phase
Looking for initial rollout to a small group of hospitals around April 25th
Will seek feedback from the early adopters
• Credit Balance Reporting
– Currently in the design phase
– Anticipating 3 month development and testing
• Payment Integrity Reviews
– Currently in the design phase
– Anticipating 6 month development and testing
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Timeline
• March 21, 2011
Third Party Reviews
• April 25, 2011
Self-Disclosures
• July 1, 2011
Credit Balance Reporting
• October 1, 2011
Payment Integrity Reviews
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