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Opening and Closing the Door to Medicaid
Program IntegrityEric D. Torres, J.D.Program Integrity – Compliance Unit
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PURPOSE
Assure the Programmatic and Fiscal Integrity of the Louisiana Medical Assistance Program including but not limited to Medicaid.
MEDICAID FRAUD, WASTE, AND ABUSE
ENOUGH IS ENOUGH……..IT IS TIME TO GETTOUGH!
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Primary Functions
Provider EnrollmentAdministrative SanctionsDetectionInvestigationEnforcementPayment Error Rate Measurement(PERM)RAC
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Rules of the Game
MAPILLouisiana Statutes 42:437.1SURS RULELouisiana Register Vol. 29m No. 04, April 20, 2003Federal Laws and RegulationsProgram RegulationsProvider Manuals/ Standards for PaymentsLetters from the Medicaid DirectorTraining ManualsProvider UpdatesRA Messages
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General Conditions Of Enrollment
Your Enrollment in Medicaid is a contractual arrangement.By entering into that contract you have agreed to certain conditions.The general conditions are contained in the PE-50 Addendum – Provider Agreement.
PE-50 ADDENDUM
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PE-50 ADDENDUM – PROVIDER AGREEMENTProvider Name: __________________________________I, the undersigned, certify and agree to the following:Enrollment in Louisiana Medicaid1. I have read the contents of this Louisiana Medical Assistance Program Enrollment Packet and the information supplied herein is true, correct and complete;2. I understand that it is my responsibility to ensure that all information is kept up to date on the Louisiana Medicaid Provider File;3. I understand that failure to maintain current information may result in payments being delayed or closure of my Medicaid provider number;4. I understand that if my number is closed due to inaccurate information, I will have to complete a new enrollment packet in its entirety to reactivate my provider number;5. I attest that I am a U.S. citizen or that I have legal status and work privilege in the U.S.6. I understand that it is my responsibility to ensure that all my employees and/or authorized representatives are U.S. citizens or have legal status and work privilege in the U.S.7. I understand that it is my responsibility to ensure that neither I, nor any owner(s), manager(s), employee(s), agent(s) or affiliate(s) are not now or have ever been:· denied enrollment;· suspended, or excluded from Medicare, Medicaid or other Health Care Programs in any state;· employed by a corporation, business, or professional association that is now or has ever been suspended or excluded from Medicare, Medicaid or other Health Care Programs in any state;· convicted of any crimes.I will report any of the above conditions to Program Integrity at the Department of Health and Hospitals prior to enrolling in Louisiana Medicaid or upon discovery once enrolled.8. I understand that as part of the Louisiana Medicaid enrollment/re-enrollment process, the Social Security Numbers of any owner(s), manager(s), and board of directors, etc., must be provided.· I understand that failure to provide the Social Security Numbers will result in the rejection of my enrollment or re-enrollment request.Providing Services to Louisiana Medicaid Recipients9. I agree to conduct my activities/actions in accordance with the Medical Assistance Program Integrity Law (MAPIL Louisiana R.S. Title 46, Chapter 3, Part VI-A) as required to protect the fiscal and programmatic integrity of the medical assistance programs;10. I understand that services and/or supplies provided by me must be medically necessary and medically appropriate for each individual patient based on needs presented on the date the service is provided and/or delivered;11. I agree to charge no more for services to eligible recipients than is charged on the average for similar services to others;12. I understand that as the provider I am held responsible for any and all claims submitted under any Louisiana Medicaid provider number issued to me;13. I agree to maintain all records necessary for full disclosure of services provided to individuals under the program and to furnish information regarding those records as well as payments claimed/received for providing such services that the State Agency, the Department of Health and Hospitals (DHH) Secretary, the Louisiana Attorney General, or the Medicaid Fraud Control Unit may request for five years from the date of service;14. I agree to report and refund any discovered overpayments;15. I agree to participate as a provider of medical services and shall bill Medicaid for all covered services performed on behalf of an eligible individual who has been accepted by me as a Medicaid patient. I agree to accept a client’s Medicaid card as payment in full for covered services rendered. I agree to bill Medicaid forallservices covered by Medicaid that will be provided to eligible Medicaid clients;16. I agree to accept Medicaid payment for covered services as payment in full and not seek additional payment from any recipient for any unpaid portion of a bill, with the exception of state-funded spend-down Medically Needy recipients as indicated by the agency’s form 110-MNP or any recipient co-payments as established by the DHH;17. I agree to adhere to the published regulations of the DHH Secretary and the Bureau of Health Services Financing, including, but not limited to, those rules regarding recoupment and disclosure requirements as specified in 42 CFR 455, Subpart B;18. I agree to adhere to the federal Health Insurance Portability and Accountability Act (HIPAA) and all applicable HIPAA regulations issued by the federal Department of Health and Human Services, including, but not limited to, the requirements and obligations imposed by those regulations regarding the conduct of electronic health care transactions and the protection of the privacy and security of individual health information and any additional regulatory requirements imposed under HIPAA;-- continued --
PE-50 ADDENDUM (CONT.)
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19. I understand the Louisiana Medicaid Program must comply with Department of Health and Human Services (DHHS) regulations promulgated under Title VI of the Civil Rights Act of 1964; Section 504 of the Rehabilitation Act of 1973, as amended; and the American Disabilities Act of 1990 which require that:· No person in the United States shall be excluded from participation in, denied the benefits of, or subjected to discrimination on the basis of age, color, handicap, national origin, race or sex under any program or activity receiving Federal financial assistance. Under these requirements, Louisiana’s Department of Health and Hospitals, Bureau of Health Services Financing cannot pay for medical care or services unless such care and services are provided without discrimination based on age, color, handicap, national origin, race or sex. Written complaints of noncompliance should be directed to Secretary, Department of Health and Hospitals, PO Box 91030, Baton Rouge, LA 70821-9030 or DHHS Secretary, Washington, DC or both.20. The Deficit Reduction Act of 2005, Section 6032 Implementation. As a condition of payment for goods, services and supplies provided to recipients of the Medicaid Program, providers and entities must comply with the False Claims Act employee training and policyrequiementsin 1902(a)(68) of the Social Security Act, set forth in that subsection and as the Secretary of the US Department of Health and Human Services may specify. As an enrolled provider/entity, it is your obligation to inform all of your employees and affiliates of the provisions of the Federal False Claims Act, and any Louisiana laws and/or rules pertaining to civil or criminal penalties for false claims and statements, and whistleblower protections under such laws and/or rules. When monitored or audited, you will be required to show evidence of compliance with this requirement.Medicaid Direct Deposit (EFT) Authorization Agreement21. I have reviewed the Medicaid Direct Deposit (EFT) Authorization Agreement and the Medicaid Provider Requirements and Conditions as listed below and agree to this agreement:· I understand that payment and satisfaction of any claims will be from Federal and State Funds; and any false claims, statements or documents, or concealment of a material fact, may be prosecuted under applicable Federal and State laws.· I understand that DHH may revoke this authorization at any time.· I hereby authorize the Louisiana Department of Health and Hospitals to present credit entries into the account and the depository name referenced on the EFT Authorization Agreement form. These credits will pertain only to direct deposit transfer payments that the payee has rendered for Medicaid services.· I certify that if a Board of Directors’ approval was necessary to enter into this agreement, that approval has been obtained and the signature below is authorized by the stated Board of Directors to enter into or change this agreement.· I agree to notify the Provider Enrollment Unit if changing financial institutions or accounts. I further understand that the maintenance of account information on the Louisiana Medicaid files is the provider’s responsibility and failure to notify the Provider Enrollment Unit as noted may result in Medicaid payments being electronically transmitted to incorrect accounts. I understand that such changes may not be able to be accommodated if less than 15 business days notice is given.Certification of Claims (Paper & Electronic)22. I certify that all claims provided to Louisiana Medicaid recipients will be necessary, medically needed and will be rendered by me or under my personal supervision;23. I understand that all claims submitted to Louisiana Medicaid will be paid and satisfied from federal and state funds, and that any falsification or concealment of a material fact, may be prosecuted under Federal and State laws;24. I attest that all claims submitted under the conditions of this Agreement are certified to be true, accurate, and complete.Print Name of the Authorized Representative Title / PositionSignature of the Authorized Representative Date of Signature
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CHANGES TO PROVIDER INFO
ChangesYou are required to report changes to Provider Enrollment in a timely mannerIt must be in writing and signed by the entities authorized agent. If it is an individual it must be signed by that individual. No phone calls or faxes are allowed.
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ChangesAll changes must come through Provider Enrollment. Making changes on the claims forms will not change your information on the Provider file.If you have a license you must also report changes to the Licensing agency as well as Provider Enrollment.
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Questions and Answers
ClosureProvider Numbers are routinely closed for various reasonsReturned mail18 months of no claims activity (auto-closure)Exclusions or Licensing issues
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Questions and Answers
Contacting Provider EnrollmentVia Phone225-216-6370Via MailMolina Provider Enrollment,P. O. Box 80159Baton Rouge, LA 70898-0159Internetwww.lamedicaid.com
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Administrative Sanctions
ExcludedHealth Care Fraud(Mandatory Exclusion)Federal Regulations and the SURS Rule prohibit individuals and/or entities that have been excluded from a government funded health program and/or convicted of health care fraud from participating in Medicaid or any other federally funded health care program
Other crimes and activities(Permissive Exclusions)The SURS Rule contains other crimes and activities for which an individual and/or entity may be excluded from Medicaid.
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Administrative Sanctions
State Law now provides that an excluded individual is subject to felony conviction if that individual continues to participate in the Medical Assistance program.
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Sanctioned Providers and Individuals
Under the SURS Rule, You have an obligation to make sure that anyone who works for you has not been excluded, convicted, or restricted.Failure to do so will result in you being sanctioned and subject to recovery, fines, and possible exclusion from Medicaid
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Administrative Sanctions
Background ChecksIn order to avoid this problem providers should, and are required, to perform background checks on all owners, mangers and employees.OIG website – checked monthlyhttp://exclusions.oig.hhs.gov/search.aspxYou should also check with licensing boards
OTHER SANCTIONS
Educational LetterWithholdingRecoupmentPre-payment reviewImpose a bond or other securityImpose monetary penalties not to exceed $10,000.00List not exclusive – refer to SURS Rule
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Detection
ComplaintsVia telephone, email and paperFrom private citizens, other parts of DHH and other agenciesProcessedTriaged by Complaint TeamMatched up with opened cases through data mining
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Investigations
Self-AuditRecords for a particular billing issueProject casesRecords for a specific period are obtained on a particular billing issue.Full ReviewRecords for specific recipients for a given time period are obtained. All billings for that period are reviewed.
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Investigations
Specific ComplaintRecords related to the specific complaint are obtainedSpecial investigationsRecords for a given time period on specifically selected billing issues are obtained.
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Investigations
Obtaining RecordsFrom ProviderYou copyWe come and getWe have an absolute right to your records that relate to our Medicaid recipientsFrom our SystemWe obtain Recipient and Provider billing histories from the MMIS System and other Systems under DHH control
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Enforcement
Notice of Sanction LetterNotice of Sanction is sent to the ProviderThis will contain an explanation of what we feel you did incorrectly and inform you of the action that we are recommending.Your OptionsAccept what we find and recommendRequest an Informal and/or Appeal
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Enforcement
AcceptCall the person who is listed in the Sanction Notice and they will instruct you what to do.Request Informal Hearing or Administrative HearingMake your request in writing to the address provided in the letter.
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Enforcement
Recommendations in the NoticeThe recommended actions in a Notice of Sanction are not implemented until the administrative process is completedExceptions to this ruleNotice of WithholdThis Notice is effective immediately and will result in all your payments being heldNotice of Suspension from MedicaidThis Notice will result in you being removed as a Medicaid provider immediately
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Enforcement
Informal HearingGenerally conducted by the Medicaid Program Integrity DirectorThe reviewers are present with the information and records they reviewedIt is your opportunity to ask questions and present your side of the storyIt is not a Court proceeding or inquisition but rather a discussionYou have the option of representing yourself or you can also bring an attorney
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Enforcement
Notice of the Results of the InformalYou will receive written notice of the results of the Informal Hearing which will contain the recommended action to be takenYou can Accept or Appeal the ResultsAcceptEnd of Administrative process and recommended action will be implementedAppeal to DHH Bureau of AppealsAdministrative process is still pending and recommended actions are not implemented
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Contacts
All Notices have the contact Information in the body of the NoticePhoneThe Analyst’s name and telephone number are in the letter. Generally in the second to the last paragraphMailThe Address is also generally in the second to last paragraphDo not contact the person who signed the Notice or mail anything to address in the footer of the Notice
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Questions & Answers
What are the primary violations that you find?UndocumentedNo documentation to support the service billedIf it is not documented it was not doneMedical NecessityDocumentation in your record does not support the medical necessity of the service billed forRecord KeepingRecords are not in compliance with the Medicaid Program’s requirementsUp-codingDocumentation in your record does not support the level of service you billed forUnbundling of ServicesThe service you bill individually should have been billed in a group
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Questions & Answer
What are you going to do to me if I do not give you what you ask for?Issue a letter to hold your payments until you do.If I ignore you will you go away?Short answer is “NO.”Long answer is “Absolutely not.”
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Questions & Answers
Am I responsible for rules that I do not know about?Yes, you are responsible for all written laws, regulations and policies that apply to your provider type. Ignorance of them is not a defense in our administrative process.
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Questions & Answers
Will you hold me responsible for the actions of my employees?Yes. And, if you are aware of a problem you should inform us of the problem.
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Questions & Answers
How can I reduce my risk and liability?Read MAPIL and the SURS RuleKnow the rules of the program.Make sure your employees know the rules of the program.Follow the rules of the program.Audit yourself to make sure you are following the rules of the program.
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Questions & Answers
QUESTIONS?

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