CMS Medicaid Integrity Program

1. CMS MedicaidIntegrity Program

2. Agenda • Overview of Medicaid Integrity Program • Medicaid Integrity Group • Task Orders • Program Specifics • Questions/Discussion

3. Overview of Medicaid Integrity Program • Established via the Deficit Reduction Act of 2005 (DRA) Section 6034, signed into law February 8, 2006 • Directs HHS to enter into contracts to carry out program’s activities, including: • Review of actions of individuals or entities furnishing items for services for which Medicaid payments were made • Audit of claims for payment for items or services rendered for which a Medicaid payment was made • Education of service providers, managed care entities and beneficiaries

4. Overview of Medicaid Integrity Program • Medicaid Integrity Group (MIG) established under the CMSO • Substantially increased funding dedicated to Medicaid program integrity efforts • Provided $255M in mandatory MIP funding (not subject to annual appropriations) over 5 years • $75M per year after five years • Additional $25M annually to HHS OIG

5. Overview of Medicaid Integrity Program • Required CMS to hire 100 new employees to help protect Medicaid program integrity by providing effective support and assistance to states to combat provider fraud and abuse • 79 FTE’s to MIG • 21 FTE’s to PERM/Medi-Medi Group • Gave CMS authority hire contractors to help deal with Medicaid fraud and abuse • Required CMS to develop Comprehensive Medicaid Program Integrity Plan (CMIP) every five years and to report on the program’s effectiveness annually

6. Overview of Medicaid Integrity Program • Calls MIP the “first national strategy to detect and prevent fraud and abuse in the program’s history” • Outlines four key principles for carrying out MIP • National leadership • Accountability for the program integrity activities of CMS and it’s contractors • Collaboration with internal/external partners and stakeholders • Flexibility to deal with the changing nature of Medicaid fraud • Efforts will “yield significant savings to help sustain the program”

7. Overview of Medicaid Integrity Program Other DRA Provisions Include: • National expansion of Medi/Medi program • $180M in funding over five years—$12M in FY06 up to $60M in FY11 • Creates incentives for states to enact FCA laws by allocating a larger share of recoveries from false claims cases to states

8. Medicaid Integrity Group (MIG) • Office of Group Director • Oversees activities of the MIG • Division of Medicaid Integrity Contracting • Oversees procurements, evaluation and oversight of MIC’s • Division of Fraud Research and Detection • Identifies fraud patterns/trends, reports information to MIC’s and States • Division of Field Operations • Approx. 40 field staff located in NYC, Chicago, Atlanta, Dallas, and San Francisco • Conducts PI review of States • Provides support and assistance to States related to PI matters

9. Medicaid Integrity Contractors (MICs) • Three types: • Review of Provider MIC—Working with Division of Fraud Research and Detection, uses Medicaid claims data to identify potentially fraudulent claims and supply leads to Audit MIC • Audit MIC—Conduct desk and field audits, identify overpayments, fraud referrals. Not involved in collection of overpayments • Education MIC—Education of service providers, managed care entities, beneficiaries, and other individuals w/r/t program integrity and benefit quality assurance issues • Review of Provider and Audit MIC’s umbrella contracts (five each) were awarded in December of 2007 • Umbrella contracts allow MIC’s to bid on individual task orders

10. MIC Jurisdictions/Regional Offices Chicago: Regions 5,7 San Francisco: Regions 9,10 Also: CNMI, Guam, American Samoa New York: Regions 1,2 Atlanta: Regions 3,4 Dallas: Regions 6,8

11. Audit MIC Contractors • Health Management Systems, Inc., New York, NY • Booz Allen Hamilton Inc, Rockville, MD(awarded Task Order 0001) • Fox Systems, Inc., Scottsdale, AZ • Health Integrity, LLC, Easton, MD • Island Peer Review Organization, Lake Success, NY

12. Review of Provider Contractors • Safeguard Services, LLC, Plano, TX • IMS Government Solutions, Falls Church, VA • AdvanceMed Corp, Rockville, MD • division of CSC, Inc. • The Medstat Group, Inc., Ann Arbor, MI • division of Thomson Healthcare • ACS Healthcare Analytics, Washington DC • division of ACS, Inc.

13. Task Order 0001 • Awarded in April 2008: • Audit MIC Awarded to Booze Allen Hamilton • Review of Provider MIC Awarded to AdvanceMed States include: Pennsylvania Maryland Delaware Washington DC Virginia West Virginia North Carolina South Carolina Georgia Alabama Mississippi Tennessee Florida Kentucky Approximately 10,000 audits projected

14. Task Order 0002 Awarded to HMS in September 2008: States include: Texas New Mexico Oklahoma Arkansas Louisiana Colorado Utah North Dakota South Dakota Wyoming Montana Approximately 2,500 to 10,000 audits; depending on award level

15. Program Specifics • MIC are to enter Joint Operating Agreements with States to “clearly define respective roles and responsibilities of contractors and third parties.” • Audit MIC contractor receives leads from CMS/Review of Provider MIC • CMS to ensure that no ongoing investigations are underway for audit targets • Audit MIC contractors make referrals of potential fraud to OIG and CMS simultaneously using CMS provided form • CMS developing case management system for contractors to utilize for managing audit activity

16. Program Specifics • CMS developed detailed Audit Protocols for Audit MICs to utilize when conducting audits • Includes CMS, state, and provider notification instructions and templates • Audits will cover all FFS providers – no managed care/encounter data auditing in the initial period • Audit targets include: Physicians/ Practitioners Home Health/Skilled Nursing Hospice Hospital Nursing Facility/ Nursing Home Renal Dialysis DME Transportation/ Ambulance Labs/ X-ray Pharmacy

17. Program Specifics Audit types include: Focused Desk – vast majority Focused Field Comprehensive Cost Report • The MIC will initiate and conduct audit per GAGAS • Audit results will be shared with states for input before final notice to providers • The MIC is to assist states in overpayment recovery, including necessary resources for state level appeal 16

18. Questions?