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Welcome and Introductions

August 2007. 2. III.Identify Current Issues. Quality Encounter Data NeededEnforcement of Contract Requirements - Written Documentation/Actual Practices, Corrective Action PlanFraud and Abuse Information Sharing, Reporting Systems MC Plans Need to Report Problem Providers Reimbursement Metho

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Welcome and Introductions

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    1. August 2007 1 Welcome and Introductions Guidelines for Addressing Fraud and Abuse in Medicaid Managed Care (October 2000) http://www.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp#TopOfPage NOTE: Scroll to bottom of page and select Managed Care - click on fraudgd.pdf. Guidelines for Constructing a Compliance Program for Medicaid Managed Care Organizations and Prepaid Health Plans (May 2002) http://www.cms.hhs.gov/FraudAbuseforProfs/02_MedicaidGuidance.asp#TopOfPage NOTE: Scroll to bottom of page and select Managed Care – click on mccomplan.pdf. The Florida Senate Interim Project Report 2006-133 (November 2005) http://www.flsenate.gov/Publications/2006/Senate/reports/Workprogram/pdf/workprogram.pdf (Page 97) Ohio Performance Audit (December 2006) http://www.auditor.state.oh.us/AuditSearch/Reports/2006Ohio_MedicaidProgram_12_19.pdf NOTE: This file will take approximately 11 minutes to download.

    2. August 2007 2 III. Identify Current Issues Quality Encounter Data Needed Enforcement of Contract Requirements - Written Documentation/Actual Practices, Corrective Action Plan Fraud and Abuse Information Sharing, Reporting Systems – MC Plans Need to Report Problem Providers Reimbursement Methods – MC Fee-For-Service Payments to Plan Providers HIPAA Compliance by MC Plans – Information Sharing Outsourcing by MC Plans - Customer Service and Medical Record Review Overseas Duplicate Enrollments – Plan to Plan, State to State, County to County

    3. August 2007 3 III. Identify Current Issues (continued) TPHI Recoveries and Accurate Reporting – Underreporting Contracted Services – Incentive to Provide Little Service for Set Rate Plans not Paying Providers’ Claims Underutilization - Non-Assignment of Recipients Timely Inappropriate Payments – Deceased, Incarcerated True Cost of Services - Kickbacks to Suppliers, Rebates from Hospitals and Other Providers to the MC Plan Carve-Outs – Steering to Carve-Out Providers Rather Than MC Plan Providing Services

    4. August 2007 4 Workgroup Objectives ? To conduct an environmental assessment of the MCO arena, including: Identification of the major players (i.e., MCOs with multi-state engagements) Compilation of state contacts of the organizations/bureaus/etc., directly responsible for managing the MCO relationships Development of a “clearinghouse” of various actions taken including audits, investigations, and prosecutions ? To develop a list of potential audits and data matches used by other states to address overpayments in the managed care area ? To develop a model for a Compliance Audit Plan (CAP) which incorporates experiences and best practices from the various states who have been engaged in this type of activity

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