Medicaid Integrity Program State PI Reviews CMS Medicaid Integrity Group Division of Field Operations

1.  Medicaid Integrity Program State PI ReviewsCMS Medicaid Integrity Group Division of Field Operations 23rd Annual NAMPI Conference Coronado, CA August 28, 2007

2. Deficit Reduction Act of 2005: MIP Statutory Requirements Created Medicaid Integrity Program (MIP) Contracts for Claims Review, Audits, Overpayment Identification & Education Effective Support and Assistance to States

3. Effective Support & AssistanceFour Primary Strategies Fraud research Investigative support & coordination Training & technical assistance PI Institute; CPT coding; SMDs; etc. State program integrity assessments State PI reviews PI metrics

4. DFO Staffing Key administrative roles Deputy Directors in NY & SF Coordinators for provider audits, policy, law enforcement and state PI reviews Medicaid Integrity Specialists Hiring in progress Variety of skills/backgrounds Basic training including state PI operations Possible state PI internships

5. MIS Responsibilities All PI reviews State PI liaisons for training & technical assistance Audit results coordination

6. Division of Field Operations 30 Medicaid Integrity Specialists assigned to one of 5 field offices NYC ROs I/II Atlanta ROs III/IV Chicago ROs V/VII Dallas ROs VI/VIII San Francisco ROs IX/X

7. Medicaid Alliance for Program Safeguards MAPS Limited resources Relied on regional office staff and unpredictable travel funds Evolving process 45 reviews of 44 states between FY00 & FY 06

8. MAPS Reviews 23 states were in regulatory non-compliance – 21 states no problem Inconsistent follow up Confidential reports Annual national summary

9. MIP Review Goals“Make one state’s best practices every state’s common practices” Statutory & regulatory compliance Identification of best practices NY – “post & clear” Vt – 100% annual recert of provider Identification of vulnerabilities Numerous states: poor MFCU relations MIG developing referral performance standards Opportunities for technical assistance Improve Medicaid PI nationally

10. MIP Reviews 3 types of program integrity reviews Focused (e.g. Medi-Medi readiness) Corrective action follow ups Comprehensive States will be on 3 year comprehensive review cycle Other reviews as appropriate Public reports

11. Comprehensive Review Process 8 weeks notice of onsite review State material due 30 days in advance of onsite 3-4 CMS staff onsite for one week Interview all key staff, including MCOs & MFCU Review guide continues to evolve Qualitative judgments

12. States Under Review FY 07: CT, MI, NV, AR, DE, VA, MO, OR FY 08: GA, IL, IA, MN, NM, NC, ND, OK, PA, PR, SC, SD, TN, TX, UT, VT, WY OIG OEI Evaluation

13. Frequent IssuesAll Reviews Through July 2007 42 CFR 455.106 Provider disclosure of criminal convictions 22 states State discretion to disqualify provider 42 CFR 455.104 Provider disclosure of ownership info 13 states FFP not available for non-responsive providers

14. Frequent Issues (cont) 42 CFR 455.106 States reporting adverse actions to OIG 9 states OEI study near completion 42 CFR 455.105 Provider disclosure of business transactions 7 states Potential loss of FFP for non-responsive providers

15. Questions? Robb Miller 312-353-0923 Robb.miller@cms.hhs.gov For copy of PI Review Guide Pamela.howard@cms.hhs.gov