Medicaid Recipient Audits and More

1. Presented by: Allee Ponton, RAU Supervisor www.dmas.virginia.gov Medicaid Recipient Audits and More

2. Agenda • Introduction • The More • Program Integrity Division • Provider Fraud • Staff • The work • Our authority • When to make a referral to RAU • How to make a referral to RAU • The referral process • What happens when RAU receives a referral • Findings • Questions – Please ask throughout the presentation • Contact Informaton

3. The Department of Medical Assistance Services (DMAS) Our Mission To improve the health and wellbeing of Virginians through access to high-quality health care coverage. Collaboration Service Trust Our Values Adaptability Problem-Solving

4. Program Integrity (PI) Mission & Tag Line OUR MISSION: The Program Integrity Division (PID) is entrusted with the responsibility of ensuring the Virginia Medicaid Program is equipped to combat waste and abuse and refer potentially fraudulent providers and members to the proper law enforcement entity. OUR TAG LINE: Each dollar lost to fraud is one less dollar available for someone in need of care

5. Our Division • Currently there are two units in the Program Integrity Division: • Provider Review and Audit Contractors • Member / Eligibility Reviews

6. Provider Fraud Provider Fraud is investigated by the Medicaid Fraud Control Unit (MFCU) • MFCU Hotline • 1-800-371-0824 • MFCU Email • MFCU.mail@oag.state.va.us

7. Our Staff Approximately 20 staff plus contractor

8. The Work Eligibility Review Recipient Audit Unit (RAU) Investigates allegations of acts of fraud or abuse committed by members of the Medicaid and FAMIS programs. Collaborates with local DSS eligibility and fraud workers on issues related to recipient fraud, waste, and abuse. Collaborates with local DSS agencies in the investigation of alleged acts of criminal welfare fraud and the referral of these allegations to local Commonwealth Attorneys. Public Assistance Reporting Information System (PARIS) LDSS Site Visits • Payment Error Rate Measurement (PERM) • Medicaid Eligibility Quality Control (MEQC) • Eligibility Quality Review Program (EQRP) • Medicaid Expansion Audits • Public Assistance Reporting Information System (PARIS)

9. LDSS Site Visits • Road Trip Initiative

10. What is our authority? • DMAS/RAU has sole authority over cases of suspected Medicaid fraud when eligibility for a public assistance payment is not involved (Medicaid only cases). • M1700.200B (Medicaid Manual)

11. When should the LDSS make a referral to RAU? Report to RAU every known instance relating to a non-entitled individual’s use of Medicaid services, regardless of the reason for non-entitlement such as: • Instances where evidence of fraud may exist. • Errors involving eligibility discovered by the LDSS in which it appears there has been deliberate misrepresentation by an applicant/recipient with intent to defraud. • Eligibility errors discovered by the LDSS, independent of other audit or quality control functions, including cases in which the individual was enrolled incorrectly, added in error, not cancelled timely, allowed to remain on Medicaid during the conviction sanction period or when information known to the agency would render ineligibility. • Cases in which the LDSS discovers that the enrollee failed to report information that impacts eligibility. • LTC patient pay underpayments resulting from any cause totaling $1,500 or more.

12. How to make a referral to RAU? Remember - - Report every known instance relating to a non-entitled individual’s use of Medicaid services, regardless of the reason for non-entitlement. The process: • Complete the DMAS 751R,Notice of Medicaid Recipient Fraud/Non-Fraud. • The DMAS 751R should also be completed and submitted for joint criminal cases, SNAP/Medicaid. • Complete the DMAS 752R, Notice of Recipient Long Term Care (LTC) Patient Pay Underpayment, for LTC Underpayments. • Complete the DMAS 750R, Medicaid Claims Request, for TANF and Auxiliary Grant (AG) • All forms can be found on the FUSION page in the SPARK forms library area.

13. The Referral Process - Complete the DMAS 751R

14. The Referral Process – Include with DMAS 751R (1/2) Include the following information with your DMAS 751R: • Confirmation that ongoing eligibility has been reviewed in relation to the allegation and results. • Reasons for and dates of alleged ineligibility for Medicaid. • Recipient’s Social Security Number. • Applicable Medicaid applications or review forms for the referral/ineligibility. • Address and telephone number of any attorney-in fact, authorized representative, or other individual who assisted in the application process. 9

15. The Referral Process – Include with DMAS 751R (2/2) Include the following information with your DMAS 751R (continued): • Relevant covered group, income, resource, and/or asset transfer documentation. • A copy of any Regional Specialist’s decision regarding trusts. • Any record of communication between the agency and the client or representative, such as case narratives, letters, and notices. • Information obtained from the LDSS’ fraud investigation, including names and addresses of knowledgeable individuals for testimony and/or interviews. • If the information is not sent with the referral indicate on the referral if the information has been uploaded or is available on DMIS.

16. The Referral Process -PARIS Referrals The Process for PARIS Referrals: • If a PARIS match is found, the PARIS User Guide, is available at https://fusion.dss.Virginia.gov/broadcasts/article/589/eligibility-actions-for-paris-matches , which contains the procedures for researching and reporting PARIS-matched individuals. • Broadcast 10818 • Also reference the Medicaid Manual, M1510.100 Number 4. 11

17. The Referral Process - DMAS 752R

18. The Referral Process - DMAS 750R

19. The Referral Process –Submitting a Referral Referrals can be sent by mail, email or fax: • Mail: Recipient Audit Unit 600 E. Broad St, Suite 1300, Richmond, VA 23219 • Email: recipientfraud@dmas.virginia.gov • Fax: 1-804-452-5472

20. General public and anonymous referrals The general public or any individual who would like to remain anonymous can also make referrals to the RAU in the following manner: • Email: recipientfraud@dmas.virginia.gov • Hotline: 1-866-486-1971 or 1-804-786-1066 • Fax: 1-804-452-5472 • Mail: Recipient Audit Unit • 600 E. Broad St, Suite 1300 • Richmond, VA 23219

21. What does RAU do after the referral is received? • RAU will send an acknowledgment letter to the LDSS worker making the referral. • The referral is assigned for processing. • When the investigation is completed the appropriate correspondence will be sent to the appropriate parties documenting RAU’s findings.

22. Findings – Main referral sources FY2018

23. Findings

24. Findings Top Allegation Types • Income / Financial • Household Composition • Patient Pay Underpayemt • Agency Error • Appeal Related • Uncompensated Transfer

25. Findings FY2018 FY2019 (to date) Overpayments Identified Total Amount Administrative: $5,435,607.52 Administrative Member - $3,525,836.05 Agency Error - $1,909,771.47 Criminal Referral Amount: 23 referrals - $428,739.71 Criminal Convictions: 8 convictions - $57,478.97 ordered restitution Overpayments Identified Total Amount Administrative: $5,464,715.99 • Administrative Member - $3,710,051.38 • Agency Error - $1,754,664.61 Criminal Referral Amount: • 43 referrals - $500,693.50 Criminal Convictions: • 18 convictions - $142,191.69 ordered restitution

26. ??? ??? Q & A ??? ??? 18

27. Contact information Yolanda D. Chandler Recipient Audit Manager (804) 588-4879 Yolanda.Chandler@dmas.virginia.gov Allee Ponton RAU Supervisor (804) 371-0881 Allee.Ponton@dmas.virginia.gov Nancy Branch Eligibility Review Supervisor (804) 418-4419 Nancy.Branch@dmas.virginia.gov 17

28. Medicaid Recipient Audits and More BPRO 2019