Transcript Linda M. Altenhoff, DDS - Texas Oral Health Coalition

Detecting and Decreasing
Waste, Abuse & Fraud
Office of Inspector General
2013
Texas Oral Health Coalition, Oral Health Summit
November 22, 2013
Office of Inspector General
Governor
EXECUTIVE COMMISSIONER
Health & Human Services
Commission
COMMISSIONER
COMMISSIONER
COMMISSIONER
Inspector
General
COMMISSIONER
DADS
DSHS
DFPS
DARS
Aging & Disability
Services
State Health
Services
Family & Protective
Services
Assistive & Rehab
Services
Areas of Responsibility
Burdens of Proof:
• Office of Inspector General (OIG)
Administrative – preponderance of evidence
• Office of Attorney General (OAG)
Civil & Criminal – culpable mental state
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Each recognize various levels of involvement:
Knowingly
Intentionally
Recklessly
Willfully
Negligence
Waste, Abuse & Fraud
The Causes
What is Waste, Abuse, & Fraud?
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Waste
Practices that a reasonably prudent person would deem
careless or that would allow inefficient use of resources,
items, or services.
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Abuse
Practices that are inconsistent with sound fiscal, business,
or medical practices and that result in unnecessary program
cost or in reimbursement for services that are not medically
necessary, do not meet professionally recognized standards
for health care, or do not meet standards required by
contract, statute, regulation, previously sent interpretations
of any of the items listed, or authorized governmental
explanations of any of the foregoing.
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Fraud
Any act that constitutes fraud under applicable federal or
state law, including any intentional deception or
misrepresentation made by a person with the knowledge
that the deception could result in some unauthorized benefit
to that person or some other person. Fraud may include any
acts prohibited by the Texas Human Resources Code,
Chapter 36 or Texas Penal Code, Chapter 35A.
‘Red Flags’ of Fraud
Personal Pressures
• Finances.
• Personal Feelings.
Personal Characteristics
• Rationalization of behavior.
• Lack of stability.
Organizational Opportunities
• Accounting practices.
• Firm characteristics.
Organizational Pressures
• Business decisions.
• Legal difficulties.
Institute of Internal Auditors – Ethics Panel:
Who Commits Waste, Abuse & Fraud?
Anybody can!
– State employees.
– Managed Care Organizations.
– Contractors and subcontractors.
– Providers and their staffs.
– Recipients and beneficiaries.
Waste, Abuse & Fraud
The Problem
Provider Fraud
Main Concerns:
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Inflating bills.
Double-billing.
Up-coding / unbundling.
Billing for unnecessary services.
Billing for services never rendered.
Reporting phantom visits.
Inappropriate cost shifting.
Billing for service previously provided.
Durable Medical Equipment Fraud
Main Concerns:
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Drop-shipping supplies.
Defective wheelchairs and other equipment.
Fraudulent billing.
Not checking with clients.
Falsification of signatures.
Solicitation.
Documentation.
Medical Transportation Fraud
Main Concerns:
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Emergency vs. Non-Emergency.
Misrepresenting the client’s condition.
Billing for en-route supplies when none used.
Indicating ‘severely disabled’ when not.
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Cancelled requests or no-shows.
No Medicaid-covered services received.
False claims for transport outside county.
False authorization.
Healthcare Organization Fraud
Main Concerns:
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Procurement of managed care contracts.
Marketing, enrollment, and de-enrollment.
Underutilization.
Claims submission and billing procedures.
Antitrust violations.
Fraud or abuse in the FFS component.
Embezzlement and theft.
Beneficiary Fraud
Main Concerns:
Eligibility:
• Income – Resources.
• Family composition / Residency.
Misuse of Benefits:
• Recipient card sharing.
• Misuse of medical services.
• Misuse of prescription medications.
• Altering of prescriptions.
• Trafficking in Lone Star Cards.
• Failure to report private insurance.
Waste, Abuse, & Fraud
The Process
The Usual Process
• Allegation / Report
• Investigation / Finding
• Hearing / Trial
• Civil Penalties / Exclusion
Investigation Process
Medicaid Provider Integrity
• Each complaint is reviewed by an
intake investigator. The results can
be one or more of the following:
- case closure
- provider education
- referral to a licensure board
- payment hold
- referral to the Attorney General
- full scale investigation
Potential Remedies
Sanctions
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Recoupment of Overpayments
Civil Monetary Penalties for False Claims
Exclusion
Payment Hold
Contract Cancellation
Restricted Reimbursement
Recoupment of Other Funds
Administrative Actions
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Pre-Payment Holds
Educational Sessions
Prior Authorization
Corrective Action Meetings
Surety Bonds
Waste, Abuse & Fraud
The Solution
Eliminate WAF: Plan & Control
• Develop a Prevention Plan:
- Designate a key Compliance Officer
or Compliance Team.
- Outline specific roles / responsibilities.
- Specify the scope of authority.
- Define relationship with other areas
(i.e. OIG, TMHP, etc.).
- Identify and measure risks.
- Analyze all aspects of your program.
- What are your ‘Red Flags’?
- What factors are critical?
- Identify what is in your direct control,
and what isn’t.
Eliminate WAF: Educate & Implement
• Develop Learning Functions:
- Train in awareness and prevention.
- Intake staff in telephone skills, probing
questions, program specifics.
- MTP clients, Transportation provider,
Medical providers in responsibilities.
- Implement and monitor controls.
- Create a ‘triage’ process to assess.
- Have regular discussions on potential
WAF issues and responses.
- Identify how you know you are
succeeding.
Eliminate WAF: Document & Build
• Develop Integrity Functions:
- Document everything.
- Build good data collection &
record keeping into your processes.
- Encourage continuous improvement.
- Keep current and active in state and
federal trends, initiative, and statutes
that impact your program.
- Ask, “What if . . .” to create ideas, build
innovation, and improve service.
- Don’t get stuck in, “We’ve always done
it that way.”
Waste, Abuse & Fraud
Responsibility to Report
Why Report Waste, Abuse & Fraud?
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It cheats everyone.
All these activities cost taxpayers and good providers, siphon
money from patient care, and increase state, federal, and
managed care oversight and investigative costs.
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It hurts Medicaid clients.
These activities can result in individuals not receiving care
that is medically necessary, or receiving unnecessary or
even harmful care.
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It’s illegal.
Fraud or abuse can result in civil or criminal liability. Not
only is the person who knowingly falsifies records or claims
responsible, so is the person telling them to do so and anyone
who knew or should reasonably have known what was happening.
Excessive and below standard of care
dental services
Falsified Documentation
Lower Right
Lower Left
Falsified Documentation
Panoramic x-ray
Intra-oral of lower arch
Inaccurate Documentation
2009 Bitewing x-rays
2010 Bitewing x-rays
Questions/Contact Information
Linda M. Altenhoff, DDS
Chief Dental Officer
512.491.1106
[email protected]
Contact
• OIG Website
https://oig.hhsc.state.tx.us/OIG_home.aspx
• OIG Hotline
1-800-436-6184
• OIG Training Coordinator
Todd Shaw
512-491-2059
[email protected]