Compliance Overview

1. Compliance Overview DBH Executive Director’s Meeting February 3, 2010

2. Definition of Fraud: Any intentional deception or misrepresentation made by an entity or person with the knowledge that the deception could result in an unauthorized benefit to the entity, him/herself or another responsible person in a managed care setting. From DPW Program Standards and Requirements Appendix F

3. Definition of Abuse: Any practices that are inconsistent with sound fiscal, business, or medical practice and which result in unnecessary cost to the MA program, or in reimbursement for services that are not medically necessary or that fail to meet professionally recognized or contractual obligations(including the terms of the RFP, contracts, and requirements of state or federal regulations) for health care in the managed care setting.

4. From the CBH Provider Agreement:“Provider shall use good faith efforts to develop and maintain a corporate compliance program in accordance with standards set forth in the Provider Manual with the objective of preventing fraudulent billing and/or embezzlement of funds. “

5. 7 Elements of a Compliance Programfrom Appendix F of the DPW PS & R • Written policies, procedures and standards of conduct that articulate the organization’s commitment to comply with all Federal and State standards related to Medicaid managed care organizations • Designation of a Compliance Officer and a Compliance Committee that is accountable to senior management • Effective training and education for the compliance officer and employees

6. 7 Elements of a Compliance Program(cont’d) • Open, effective lines of communication from employees to the compliance officer such as a Hotline • Enforcement of standards through well-publicized disciplinary guidelines • Internal monitoring and auditing • Provisions for prompt response to detected offenses and the development of corrective action initiatives

7. Audit Process • Provider is scheduled-usually according to Credentialing schedule • Sample is created by analysts • Review of records completed • Preliminary Report generated by analysts

8. Audit Process (cont’d) • Report is reviewed by the Compliance Committee: • providers with error rates of less than 10% are reviewed only • providers with error rates of 10-25% are reviewed and discussed with the committee • providers with an error rate over 25% are reviewed, discussed and automatically invited in for a meeting to discuss the results • Results are shared with provider via letter and with a copy of the Compliance report and then they have an opportunity to respond • Audit finalized.

9. Preliminary Internal Report on xxx Parent ID: Provider Number: Date of Audit: Type of Audit: Regular Auditor: Types of Services Audited: Number of Records Reviewed: Total $ Amount of Claim Lines in Sample: $ Total Variance in Sample: $

10. Preliminary Internal Report on xxx (cont’d) Total Lines in Variance: Error Rate: % Total Amount of Claims Paid from XXX to Present: $ Extrapolated Error Amount  Comparison To Previous Audit: Concerns This Year Included In the Variance :  Concerns This Year NOT Included In the Variance :   Recommendations: ·

11. Error Rates in 2009 • Inpatient Hospital, incl. EAC, Detox, Rehab: Average 18%, Low: 0%; High: 64% • Non-Hospital Rehab & Detox: Average: 38%; Low: 0.5%; High: 86% • OP MH: Average: 48%; Low: 0%; High: 100% • OP D&A: Average: 54%; Low: 16%; High: 100%

12. Error Rates(cont’d) • IOP: Average: 47%; Low: 26%; High: 70% • BHRS: Average: 46%; Low: 9%; High: 72% • RTF: Average: 12%; Low: 0%; High: 89%

13. Error Rates (cont’d) • In 2009 262 programs were audited • Error Rate 0-10.0% 58 programs • Error Rate 10.1-25% 43 programs • Error Rate 25.1-35% 25 programs • Error Rate 35.1-45% 27 programs • Error Rate 45.1-55% 20 programs • Error Rate 55.1-65% 28 programs

14. Error Rates (cont’d) • Error Rate 65.1-75% 29 programs • Error Rate over 75% 32 programs

15. Common Errors • Legibility • Treatment Plans • Duplication across individuals and across periods • Must be signed by a physician in Medicaid • Must relate to the assessment/evaluation • Evidence that individual directed the process

16. Common Errors (cont’d) • Progress notes • All timed services must have a start and end time • Must capture what the intervention was and what the response was • Re-using identical content in multiple notes • Staff not following the agency’s own policies regarding format, correcting errors, etc.

17. Reporting Issues • Provider Issue • Investigate Issue and determine course of action • Provide CBH with written correspondence outlining what the issue is, how it was discovered, what actions have been taken to prevent a recurrence. Repayments to CBH need to state the name of the member, the invoice number, the type of service and the date of service-this can be done a Claims Adjustment Form or on an Excel spreadsheet

18. Reporting Issues (cont’d) • Staff Issues • Investigate issue and determine course of action • Provide CBH with written correspondence outlining what occurred, how it was discovered, what steps have been taken to investigate and what actions the provider has taken

19. Reporting Issues (cont’d) • DPW has a self-auditing protocol that can be used by providers as well. The protocol can be found on the DPW website, www.dpw.state.pa.us/omap in the Fraud and Abuse section.

20. Reporting Issues (cont’d) • Staff Issues • Providers can report directly to Bureau for Program Integrity at 1-866-DPW-TIPS or through the BPI page of the DPW website • CBH is also required to report to BPI

21. Future Actions • Expand samples • Targeted in-house reviews of claims such as TSS School billing on Non-School days and IOP • Level of care specific audits across providers • Extrapolate • Provider Self-audits on a particular type of claim for a particular time period • Error rate published in Provider Profiles • Suspend referrals

22. Discussion