Transcript California Department of Health Services

California Department of
Health Care Services
Audits and Investigations,
Medical Review Branch,
March 2008
Audits & Investigations
Mission Statement
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To protect the fiscal integrity of
California’s publicly funded health care
programs.
To ensure quality health care services are
delivered to Medi-Cal Beneficiaries.
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Medi-Cal Fraud
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Medi-Cal fraud represents a complex and
multi-faceted problem.
New fraudulent schemes continue to
surface.
Unscrupulous providers are continually
testing our ability to identify misuse of the
Medi-Cal Program.
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What does fraud look like?
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Fraud presents itself in many forms:
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Improper use of beneficiary IDs
Providers rendering services that vary from norms
Providers billing for services not rendered
Providers exploiting vulnerable populations for
economic gain
Improper use of provider IDs
Providing services that are not medically necessary
Payment of “kickbacks” to beneficiaries (capping) in
order to bill Medi-Cal for unnecessary services
Failure to disclose true ownership on Medi-Cal
application (willful misrepresentation)
Up coding to obtain a higher rate of reimbursement
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The Cost of Fraud
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Research confirms that fraud costs the
Program a great deal.
Small numbers of beneficiaries can
generate repetitious billings by
providers for enormous sums in
fraudulent payments.
Collusion among providers is a popular
scheme utilized to defraud the Medi-Cal
Program.
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The Cost of Fraud is
Significant
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1,915 beneficiaries during a 12
month period cost the Medi-Cal
program $67,000,000 in outpatient
services
Or, $34,987 per-user
Or, $2,916 per user-per-month
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Anti-Fraud Savings
As a result of Anti-Fraud efforts
over $2 billion savings since 1999
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Cumulative Anti-Fraud Savings
July 1, 1998 through June 30, 2007
SAVINGS
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Re-Enrollment
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Withholds
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Temporary Suspensions
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Special Claims Review
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Provider Prior
Authorization
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Field Audit Reviews/UC
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Audits for Recovery
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Lab Reviews
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Dental
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BIC Replacement
TOTAL $1,204,541,873
COST AVOIDANCE
Pre-Enrollments
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Lab Enrollment
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Managed Care
TOTAL
$752,415,141
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LEGAL ACTIONS
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Criminal Convictions
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Civil Judgments/Settlements
TOTAL
$ 138,413,550
Court Ordered Restitution
TOTAL
$78.9 million
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Data sharing with CMS
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California was the first state to partner
with the Federal Centers for Medicare and
Medicaid Services (CMS) in data-sharing
on providers
Provides more detailed information on
suspect providers
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Key Legislation
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AB1699 (2002)
Added Section 100185.5 to the Health and Safety Code and authorizes the
Director to deny continued enrollment, suspend, or withhold payments to a
Medi-Cal Provider if they duplicate fraud from one program to another or have
had multiple utilization controls.
SB 857 – (2004)
Amends several sections of the Welfare and Institution Code (W&I) adding
provisional provider status, providing DHCS with the ability to levy civil money
penalties, collect overpayments in a more timely manner, and impose procedure
code limitations when warranted.
AB 530 – (2006)
Added Section 14123.05 to the W&I Code and became effective January 2007.
Gives sanctioned Medi-Cal providers the opportunity to participate in meet &
confer meetings with DHCS.
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Investigations Branch Investigations,
Reviews and Techniques
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The Investigations Branch (IB) is charged with the
responsibility to protect the fiscal integrity of the
California’s publicly funded health care programs.
IB Fraud Investigators are sworn law enforcement
officers who conduct criminal and civil investigations into
various Medi-Cal program fraud, both beneficiary and
providers.
Medi-Cal Beneficiary Fraud:
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Early Fraud Detection Program (EFDP)
Income Verification Eligibility Verification System (IEVS)
Failure to Report Other Insurance Coverage
Drug Utilization Enforcement (DUE)
Social Security – Cooperative Disability Investigations
In Home Support Services
Women, Infants and Children Program (WIC)
Vital Statistics Investigations
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Allied Agencies
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IB Fraud Investigators work with numerous allied
agencies, including:
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The county welfare departments, eligibility workers, social
workers, the special investigative units (Welfare Fraud
Investigators) and the county Auditor Controllers Office
Federal Agencies:
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State Departments:
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The FBI, Health and Human Services, the Social Security
Administration, Federal Courts, Housing Utilization and
Development (HUB) and the Drug Enforcement Administration
The State Controllers Office, Franchise Tax Board, Department of
Justice, Bureau of Medi-Cal Fraud and Elder Abuse, the Bureau of
Narcotics Enforcement, State Department of Social Services, Adult
Programs and Fraud Bureau, the California Welfare Fraud
Investigators Association, the California Department of Consumer
Affairs, Department of Mental Health, Alcohol and Drug Program,
Department of Development Disabled and the Highway Patrol
City and Local Departments:
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Police and sheriff, county grand juries and county counsel
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2007 Payment Error Rate
Measurement (PERM)
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The Centers for Medicare & Medicaid Services (CMS)
implemented the PERM program to measure improper
payments in the Medicaid program and the State
Children's Health Insurance Program (SCHIP).
PERM is designed to comply with the Improper Payments
Information Act of 2002 (IPIA; Public Law 107-300),
which requires a report to Congress.
Three contractors perform statistical calculations,
medical records collection, claims review and
medical/data processing review of selected State
Medicaid and SCHIP fee-for-service (FFS) and managed
care claims.
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2007 Payment Error Rate
Measurement (PERM)
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In FY 2006, CMS reviewed only fee-for-service
Medicaid claims.
In FY 2007, PERM was expanded to include
reviews of fee-for-service and managed care
claims, as well as beneficiary eligibility, in both
the Medicaid and SCHIP programs.
Each state participates in the PERM program
once every 3 years (17 states per year) on a
rotational basis. All 50 states are reviewed every
3 years.
California is a year 2 state (2007, 2010, 2013…).
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2007 Payment Error Rate
Measurement (PERM)
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Based upon the error rate, states must return their
Federal share of overpayments within 60 days.
CMS published the final rule for PERM on August 31,
2007, which sets forth State requirements for
submitting claims and policies to the CMS Federal
contractors for purposes of conducting fee-forservice and managed care reviews. This final rule
also sets forth the State requirements for conducting
eligibility reviews and estimating case and payment
error rates due to errors in eligibility determinations.
The California MPES is the equivalent to the PERM.
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Medi-Cal Payment Error Study (MPES)
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The first MPES was conducted in 2004. DHCS is
currently conducting the fourth annual MPES.
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The MPES has been conducted yearly. After this
year, MPES will be conducted every two years.
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This study allows the State to measure the error
rate of payments for Medi-Cal services and will
enhance the system used to assure proper
payment for services rendered to Medi-Cal
beneficiaries.
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Medi-Cal Payment Error Study (MPES)
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The 2007 MPES is a review of a sample of claims
that were paid between April 1, 2007 and June
30, 2007 to determine if the documentation of
service supports the claims submitted for MediCal reimbursement.
The MPES develops an estimate of dollar loss
due to potential fraud, identifies and quantifies
program vulnerabilities, and identifies how best
to deploy Medi-Cal antifraud resources.
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Evaluation Activities
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Audits for Recovery
Enrollment Reviews
Utilization Reviews
Field Audit Reviews (Pre-Payment)
Special Projects
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Consequences
Utilization Controls
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Post Service Pre Payment
Audit (SCR)
Sanctions/Suspensions
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Prior Authorization
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Civil Money Penalty
(Warning Notices)
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Withhold
Temporary Suspension
Procedure Code Limitation
Permissive Suspension
Mandatory Suspension
Immediate Suspension
Civil Money Penalty
(Imposition of Fines)
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Number of Sanctions Imposed
Type
350
305
300
250
204
196
200
159
134
150
100
50
0
70 63
79
69
34
0 3
PPA
CMP-First
Warning Ltr
TS
WH
SCR
# of Open
Cases
AFR
46
Biller Reviews
1
Desk Audits
33
Education Reviews
1
Enrollments
54
FAR
133
Referrals
8
Special Projects
10
PCL
Type of Sanction
2006
2007
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Number of Cases Currently on Sanction
PCL, 173 PPA, 73
SCR, 287
WH, 321
TS, 407
Type of
Sanction
PPA
CMP-First CMP - First
Warning Ltr, Warning Ltr
TS
748
WH
SCR
PCL
# of
Providers
73
748
407
321
287
173
** According to the Medi-Cal PCL
list on Medi-Cal website there are
only 72 providers on PCL
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Number of Cases on Which Sanctions
Were Placed
Special Projects, 10
Referrals, 8
# of Providers
AFR, 46
Biller Reviews, 1
Desk Audits, 33
Education Reviews, 1
FAR, 133
PPA
CMP-First
Warning Ltr
TS
WH
SCR
PCL
2006
0
305
70
69
196
79
2007
3
204
63
34
159
134
Enrollments, 54
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CONTACT INFORMATION
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The DHCS Medi-Cal Fraud Hotline telephone
number: 1-800-822-6222
The recorded message may be heard in English
and four other languages: Spanish, Vietnamese,
Cambodian, and Russian. The call is free and the
caller may remain anonymous.
You can also send an e-mail to:
[email protected]
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