E.3 - Scenario 2 - Review Guide Module.docx

E.3 Scenario 2 – Review Guide Module 75FCMC24RJ002

Department of Health and Human Services Centers for Medicare & Medicaid Services Center for Program Integrity/ Division of State Plan and Program Integrity

Program Integrity Review Guide Module (RGM)

State Program Integrity in Managed Care To be completed by the State

Instructions for Submission of Completed Focused Review Guide Module (RGM)

Respondents are requested to submit an electronic copy of the completed RGM (including any corresponding attachments). The completed RGM must be received no later than 5 PM EST, xx/xx/xx, at the Center for Program Integrity / Division of State Plan and Program Integrity.

Review Period: The review period for your PI focused review covers the preceding 3 Fiscal Year (FYs), which is the FYs of 2021, 2022, and 2023.

· When responding to the RGM questions, the state may save responses to each question directly in the RGM, where practical, or attach appropriate response document.

· When there are corresponding attachments, please save each file as follows: MC-X (RGM question; STATE NAME, ATTACHMENT X (document name being attached).doc, pdf, xls, etc.

· Feel free to discuss any questions or concerns you have with your RTC.

Note: Some questions in this module may need to be addressed by other organizational program integrity (PI) staff. Also, in many instances, CMS will request an electronic copy of contracts, policy and/or procedure documents that should support the response. Additionally, please be sure to capture the corresponding question number (and attachment, if applicable) with each appropriate response.

Submission Timeframe: The RGM responses, corresponding attachments and supplementary tables are due no later than thirty (30) days prior to the review or COB, xx/xx/xx. Early submissions are greatly appreciated and contribute to having a better review experience.

Area of Assessment: Program Integrity in Managed Care

State Oversight of Managed Care Organizations (MCOs) - Special Investigation Unit (SIU) and Other Managed Care Organization (MCO) Program Integrity Stats and eDocuments Request

(General Overview and eDocuments Request) Please provide an electronic copy of the documentation requested throughout the RGM, if applicable:

Yes.

At a minimum, the SIU shall have at least two (2) fraud, waste, and abuse investigators and one (1) fraud, waste, and abuse coordinator.

State PI Unit Overview

What types of data mining does the state conduct?

What types of algorithms does the state use to analyze claims data?

What type of system/software is used?

It is a MCO contract requirement that the MCOs send both paid and denied status claims, as encounters to the state on a weekly basis.

This is a standard requirement for all MCOs.

All MCO encounters shall be submitted electronically to the state.

The system is a cloud-based system.

Program Integrity has been working with other staff to evaluate to update our data analytics algorithms to enhance our reports and also include encounter claims in the on-going reporting to identify abnormalities/issues with MCO encounter claims.

How many on-site visits were conducted by the state for each review year? Are on-site visits announced or unannounced and documented?

The State does have the ability to conduct on-site reviews, however, the only onsite activity that has been conducted regarding PI has been a collaborative and transparent process. Contract monitoring in this area will occur soon.

There is a contract requirement, but no mechanism to monitor at this time.

MC-6

Per 438.602(i), does the state have safeguards in place to ensure that the managed care plans with which the state contracts are not located outside of the United States and that no claims paid by a plan to a network provider, out-of-network provider, subcontractor, or financial institution located outside of the U.S. are considered in the development of actuarially sound capitation rates?

The state has safeguards in place to ensure that the managed care plans with which the state contracts are not located outside of the United States.

The MCO shall not be located outside of the United States. The MCO is prohibited from making payments or deposits for Medicaid covered items or services to financial institutions located outside of the United States.

State and Medicaid Fraud Control Unit (MFCU) Relationship

MC-7

Does the MFCU notify the State agency orally or in writing of its request that the State agency not suspend payments under the law enforcement good cause exception in 455.23(e)?

_____ Orally _____ In writing _____ N/A: Neither orally nor in writing.

If the MFCU provides the request orally, does the MFCU follow up with a written request?

Yes _____ No _____

The MFCU notifies the state both verbally and in writing when it requests that the state agency not suspend payments under the law enforcement good cause exception in 42 CFR 455.23(e).

Yes, the state agency is notified by the Medicaid Fraud Control Unit via email.

The MFCU has expressed informally and during meetings they are concerned about the quantity and quality of case referrals from MCOs.

General Managed Care Contract Compliance

MC-10

Does the state review the MCE’s compliance program/plan as required by 42 CFR 438.608 and discuss it with the MCEs?

The State currently reviews the compliance program plan during the implementation readiness review period, and annually thereafter to ensure compliance with federal and state regulations.

A review of all MCO compliance program plans was completed and approved prior to December 31, 2023, except for one MCO who failed to submit a compliance plan.

The State requires in our contract that the contractor implement and maintain arrangements or procedures to include a compliance program plan that is designed to detect and prevent fraud, waste, and abuse in compliance with 42 CFR 438.608.

The compliance program plan shall include, at a minimum, the establishment and implementation of internal controls, policies, and procedures to prevent and deter fraud, waste, and abuse. The MCOs shall submit the compliance program plan to the state on an annual basis for review.

Is the state regularly reviewing the MCE and the PI requirements? How is this being conducted and what review tool is used to accomplish this task?

The MCOs are contractually required to have a separate fraud, waste, and abuse plan that is annually reviewed by the state.

The state performed an annual review of the MCO FWA plans in June 2023. The state was unable to review one of the MCOs FWA plan which is still in the process of being developed.

The risk questionnaires and the risk score assessment modules are the primary tools used to review MCE compliance with the fraud, waste, and abuse plan.

The PI unit and state managed care staff meet monthly and quarterly with each MCO.

The states PIU and MFCU jointly provide program integrity training to the MCOs. Additional program integrity training is conducted on an as needed basis.

FY21

Annual MCO training held August 2021-virtual due to public health emergency.

Number of MCO staff: 75

FY22

Annual MCO training held August 2022-virtual due to public health emergency.

Number of MCO staff: 32

FY23

Annual MCO training held September 2023.

Number of MCO staff: 54

Investigations

Note: Please provide the information requested in this section only if the situation applies to your state program integrity operations.

The PI unit did not perform any investigations of the MCOs during the three FYs reviewed.

2021-0 2022-0 2023-0

Provide the total number of investigations, referred directly to the State, by each MCO in each FYs reviewed.

The contract does not allow the MCOs to refer directly to the MFCU, the case must be sent to the state.

2021-0 2022-0 2023-0

Suspected FWA cases referred by the MCOs are currently not standardized for content. However, they usually contain adequate information to start a preliminary investigation. We monitor the MCOs referrals weekly and stay in communication with each plan regarding the sufficiency of the information in its referrals.

Overpayments and Recoveries

The contract requires the MCOs for the prompt reporting to the state of all overpayments identified and recovered, specifying the overpayments due to potential fraud.

Yes.

The contractor shall have retention policies for the treatment of recoveries of all overpayments from the contractor to a provider including specifically a retention policy for the treatment of recoveries of overpayments due to fraud, waste, or abuse in accordance with 42 CFR 438.608(d).

This is an area that requires development and is not being done currently. However, if in an investigation it is found that the MCO claims process should be corrected or enhanced, then the MCOs are required to make the necessary changes.

Yes.

The MCOs shall report to the state within sixty (60) calendar days when it has identified capitation payments or other payment amounts received are in excess to the amounts specified in the contract.

The state does not collect this information.

Yes.

Payment Suspensions

If not, describe why not?

The MCOs are required to suspend providers once the state has determined a payment suspension should be imposed and no exception applies. A provision for the MCOs suspension of payments to a participating provider for which the state determines there is credible allegation of fraud in accordance with the contract and 42 CFR 455.23.

No, the MCO must complete a fraud referral, submit to the PI unit, and wait direction from the program integrity unit.

MC-26

Did the state annually report its payment suspensions and required information to CMS in each FYs reviewed? If not, why not?

Yes, all years reported.

State Program Integrity in Managed Care To be completed by each selected MCO

MCO Instructions for Submission of Completed Focused Review Guide Module (RGM)

Respondents are requested to submit an electronic copy of the completed RGM (including any corresponding attachments). The completed RGM must be received no later than 5 PM EST, xx/xx/xx, at the Center for Program Integrity / Division of State Plan and Program Integrity.

Review Period: The review period for your PI focused review covers the preceding 3 Fiscal Year (FYs), which is the FYs of 2021, 2022, and 2023.

Responses shall be submitted through the state to the Review Team Coordinator (RTC) as follows:

· When responding to the CMS RGM questions, the state or MCO may save responses to each question directly in the RGM, where practical, or attach appropriate response document(s).

· When there are corresponding attachments, please save each file as follows: MCO-X (RGM question; MCO NAME, ATTACHMENT X (document name being attached).doc, pdf, xls, etc.

· Feel free to communicate any questions to CMS through your state point of contact.

*Note: Some questions in this module may need to be addressed by other organizational program integrity (PI) staff. Also, in many instances, CMS will request an electronic copy of contracts, policy and/or procedure documents that should support the response. Additionally, please be sure to capture the corresponding question number (and attachment, if applicable) with each appropriate response.

Submission Timeframe: The RGM responses, corresponding attachments and supplementary tables are due no later than thirty (30) days prior to the review or COB, xx/xx/xx. Early submissions are greatly appreciated and contribute to having a better review experience.

Area of Assessment: Program Integrity in Managed Care

MCO Program Integrity Activities General Information Requests:

Please be prepared to provide additional specific details during the virtual PI review interview.

Medicaid only.

*Beneficiary enrollment total *Provider enrollment total *Year originally contracted *Size and composition of SIU *Specify if the plan is national or local

Enrollment total should be as of January 1, 2023.

MCO SIU Investigations

How many preliminary investigations were conducted in each of the FYs reviewed?

How many full investigations were conducted in each of the FYs reviewed?

How many cases of suspected provider fraud or abuse did the MCO refer to the state in each of the FYs reviewed?

How many referrals were accepted by the state in each of the FYs reviewed?

Full Investigations

Referred to state

Referrals accepted by state

The state has not provided guidance on the elements it would like to see in a referral.

Bi-monthly meetings with the state, MFCU, and all the MCEs.

Providers are paid using the fee-for-service model.

The SIU conducts analysis of providers paid under all payment mechanisms.

The SIU receives referrals from a variety of sources including, but not limited to:

· Network and self-referral providers

· Government agencies and law enforcement agencies

· Fraud analytic software

· Data analytics

· Compliance hotline

· Publicly accessible website

· Pre-Payment Review

· Meetings with the state and MFCU

How are Medicaid managed care enrollees made aware of its existence?

There is no specific contract language requiring MCOs to have a toll-free hotline 24 hours a day. However, we have a toll-free number available during normal business hours to report fraud and abuse.

All members are made aware of the hotline via member handbook and the website.

What is the percentage of return of beneficiary verifications (calls, EOMBs, etc.) for each of the FYs reviewed?

What is the return on investment (ROI) on the verification method in place?

What action did the MCO take based on returned beneficiary verifications, reviews or surveys conducted?

No beneficiary verifications were issued or conducted during the review period. However, we have established an online system where members can access and review their claims.

Are you required to submit a report of all beneficiary verifications to the state?

Beneficiary verifications are tracked through a FWA report.

Yes, we submit the FWA report on a quarterly basis to the state.

What type of data mining does the MCO conduct?

What types of algorithms does the MCO use to analyze claims data?

What type of system/software is used?

Are there standard reports produced or is it done on an ad hoc basis?

SIU team has access to all claims data within the company.

SIU employs various types of proactive detection and prevention activities:

FWA program that assists the SIU with FWA lead generation by utilizing high impact rules and predictive analytics. This solution assists in the identification of suspicious providers and members by finding aberrant billing patterns using claims data and multivariate analysis.

FWA program designed for user-controlled analysis of healthcare data to cover potential fraud, waste, and abuse. This solution enables the SIU to track down and isolate questionable billing/payment patterns while also allowing investigators and auditors the ability to organize data and generate useful reports. The user can also perform random sampling and trend analysis.

Algorithms are designed to detect practice patterns that are outside of expected norms and identify providers who may be engaged in excessive billing.

Claims warehouse.

Standard and ad hoc reports are provided weekly, monthly, quarterly, and on an as needed basis.

What is the caseload per investigator?

Allegations, tips, and FWA leads are loaded into our case tracking system. Cases are then assigned to investigators. Average caseload per investigator is 35 active cases.

Yes. We work with our various delivery systems to identify aberrant billing.

No, the MCO SIU did not conduct investigative provider site visits because these site visits are not a requirement.

Yes

Our SIU evaluates the effectiveness of our program integrity operations by the implementation of our fraud, waste, and abuse plan, by monitoring and tracking investigative activities including case review, outcomes and provider education, actual recoveries, and cost avoidance.

SIU is committed to the fight against healthcare FWA and has established a SIU to lead this effort. The SIU developed an anti-fraud plan to support the broader compliance plan and achieve the following objectives:

• follow all federal and state rules, laws, regulations

• deter and prevent future FWA

• ensure the highest quality of care for our members and facilitate the identification and investigation of fraud

No providers were placed on a CAP.

The MCO general contract requires that each MCO have an established process to monitor its providers for non-compliance with contractual agreements. We are in the process of developing these policies and procedures.

Overpayments

Currently being developed.

Provide the dollar amount of overpayments the MCO identified and recovered (by payment mechanism) in each table for each of the FYs reviewed.

How was this information reported to the state?

Was this overpayment information reported promptly? If not, explain?

Was excess capitation or other contract overpayments reported within 60 days to the state? If not, explain why not?

Yes

Overpayment information is reported to the state annually.

Yes

No excess capitation or other contract overpayments were identified in any of the FYs reviewed.

Our overpayments identified and collected have not shown a declining trend.

Payment Suspensions

All payment suspensions are initiated by the state if the case is accepted by MFCU.

If so, please provide a copy or link to your prepayment review policy and procedure.

What percentage of the provider’s claims are reviewed during this process?

A prepayment review policy and procedure are under development.

Is the guidance being followed?

When you initiate a provider payment suspension, how do you report this information to the state?

For FY21 through FY23:

The state has not given us guidance on handling payment suspensions.

N/A

N/A

We do not have internal written policies and procedures for payment suspensions; however, we are in the process of developing the payment suspension policy.

Data Submission

How often does the MCO submit encounter data to the state?

Is there a contract requirement for the submission of encounter data?

Yes.

Encounter data is submitted to the state on a quarterly basis.

The contractor must submit an encounter claim to the state for every service rendered to a member for which the contractor either paid or denied reimbursement. Encounter data must be submitted to the state on a weekly basis.

We receive feedback for our quarterly submissions regarding incomplete encounter data. Data issues are quickly corrected.

False Claims Act

We are in the process of creating written policies for all employees of the contractor that provide detailed information about the False Claims Act.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.

INFORMATION NOT RELEASABLE TO THE PUBLIC UNLESS AUTHORIZED BY LAW:

This information has not been publicly disclosed and may be privileged and confidential. It is for internal government use only and must not be disseminated, distributed, or copied to persons not authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law image1.png