Fraud, Waste, and Abuse (Compliance) Auditing - Community Care ...

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 1 of 8POLICYCommunity Care has established a fraud, waste, and abuse detection and prevention compliance(FWA Audit) program that complies with regulations set forth by the Office of Inspector General(OIG) of the Department of Health and Human Services and with the requirements of the Bureauof Program Integrity of the Department of Public Welfare (BPI). The OIG encourages healthcare organizations to establish voluntary compliance programs to educate and attempt to controlfraud, abuse, and waste in health care. Documents have been published by the OIG that identifythe minimum elements that should be included in a compliance program, as well as specific areasof concern to the OIG. The BPI has and continues to issue guidance on the detection andreporting of suspected fraud waste and abuse.Toward that end, conducting routine FWA audits of its provider panel are performed in order todetermine potential areas of fraud and abuse, as defined below, that may be occurring. Each yearthe program audits are conducted as a result of referrals and recommendations submitted to theFWA Department by Community Care’s county and state contractors.Community Care will continuously monitor instances of potential or actual fraud and abuse inbilling by using recognized standards acceptable to the Medicaid Program and associatedregulators. Suspected or substantiated fraud and abuse under the HealthChoices contract will bereported by the Director of the Fraud, Waste, and Abuse Department, or her designee, to the BPI,to the appropriate county designee, and or oversight entity. Community Care follows allMedicaid Program regulations and BPI directives when conducting and reporting auditinformation. In addition, the Department of Public Welfare’s Medicheck list, the ExcludedParties List (EPLS), and the OIG’s List of Excluded Individuals and Entities (LEIE), are used toverify that no providers sanctioned by the State or Federal regulatory authorities are participatingin HealthChoices.DefinitionsALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 2 of 8Fraud is defined by the BPI as “any type of intentional deception or misrepresentation made byan entity or person with the knowledge that the deception could result in some unauthorizedbenefit to the entity or him/her or some other person in a managed care setting.” It includes anyact that constitutes fraud under applicable Federal or State law. Fraud may be found under thefollowing conditions (the following list is intended as an example and not as a limitation):• When a provider submits a bill for a service that was not provided; or• When a provider bills for a time period greater than the time actually spent with theclient; or• When a provider bills for the provision of a service that did not meet the servicedefinitions, performance specifications, State or Federal regulations, or accreditationstandards customarily recognized in behavioral health care.• Inappropriate or frequent referrals that may constitute a conflict of interest.• Authorizations for services to providers who may have personal or other financialrelationships with care managers.• Other related claims or care management issues that may involve intentional deception ormisrepresentation as referenced above.Waste is defined by the Office of Inspector General as the intentional or unintentional, thoughtless orcareless expenditure, consumption mismanagement, use, or squandering of government resources tothe detriment or potential detriment of government programs. Waste also includes incurringunnecessary costs as a result of inefficient or ineffective practices, systems, or controlsAbuse is defined by BPI as “any practices that are inconsistent with sound fiscal, business, ormedical practices, and result in unnecessary cost to the Medicaid Program, or in reimbursementfor services that are not medically necessary or that fail to meet professionally recognizedstandards or contractual obligations (including the terms of the [HealthChoices] RFP, Agreementand the requirements of the state or federal regulations) for health care in a managed caresetting.” It also includes recipient practices that result in unnecessary cost to the MedicaidProgram.ALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 3 of 8I. Annual Routine Compliance Auditing Procedure1. The process for annual reviews is as follows:A. Annually the FWA Department develops a work plan for each of its contractsbased on the county contractor’s recommendations, BPI and other regulatoryguidance, and internal risk assessment/data mining efforts.B. The FWA Department will adhere to the following provider auditing/chartselection methodology for audits: Identification of providers that appear to beoutliers compared to peers of the same specialty or those that perform similarservices. On an annual basis the FWA Department will select a sample ofProviders who have never been audited, or who have not been subjected to aFWA audit in the past two years. Community Care will also conduct audits ofhigh dollar providers (for the level of care being audited) for the contractednetwork. These providers are defined as those that have the highest number ofpaid claims per quarter (the three month period of time in which the provider isreviewed). Audit sample sizes may vary depending on the type of audit beingconducted, level of service, and the time frame being reviewed. A statisticallyvalid sample siz , 5%, with a minimum of 25 charts and a maximum of 75 chartsare reviewed. Suggest using a percentage D\(DPW FFS reviews 5% of recipientcharts) If it is determined that suspected fraud or abuse is identified, the samplesize will be increased, and selection methodology may change. The increase willbe determined by the number and egregiousness of the audit exceptions. Chartsand or progress notes may also be selected based on potential aberranttrends/patterns that emerge during data analysis. In these instances sample sizesare individually determined based on the analysis results, quantity of servicesperformed by the provider in the specified time period, and any relevant historicaldata related to past patterns of audit exceptions associated with the provider beingreviewed. These chart audits are conducted not only to ensure that the provider isfollowing all state, federal, and contractual agreements and regulations, but also toverify that HealthChoices recipients are receiving the services that are beingreimbursed by the Medicaid program. This verification is accomplished byALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 4 of 8documented progress notes, encounter forms, documented evidence in treatmentplans, and will include communications with members as well.C. The auditing process of routine audits is outlined as follows:a. After the provider and member selection process takes place, the providerreceives a notification letter and a telephone call that states that theprovider has been selected for an audit. The provider is either given theexact date and start time of the on- site audit, or they receive a request formember charts to be sent to Community Care for a desk audit.b. Community Care may conduct unannounced visits based on the issuesidentified in either a complaint, referral, or data mining reports.c. The provider will also receive a list of members’ charts to be reviewed atthis time. The list of member names will not be transferred electronically.Only member ID numbers will be sent via fax. The provider will be sent aletter with member names and an explanation of the auditing process.d. During the auditing process Community Care may request additionalmember charts for review.e. The notification letter not only explains the basic auditing process, but alsoallows time for the provider to ask any questions pertaining to the auditbefore the process occurs.f. No documentation will be accepted after the audit day has passed. In thecase of desk audits, no documentation will be accepted after the initialcharts are received by the auditing team. Auditors will review records andcomplete the reconciliation of documentation to claims at the provider siteif the audit was an on site review. If the audit was a desk audit, thereconciliation will occur at the auditor’s office.g. After completion of the audit, draft results are reviewed by CommunityCare FWA management, and then an exit interview is conducted withappropriate provider program directors and administrators.h. Providers are informed during the exit interview that any reimbursementsowed to Community Care may be directly deducted from future claimpayments. Direct repayment of inappropriate payments may also berequested. This information is also explained in the audit results follow-upALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 5 of 8letter that is sent to the provider within two weeks after the completion ofthe auditi. If the routine audit reveals a pattern of suspected fraud, waste, or abuse,Community Care will report the activity to BPI within 30 business days, inaccordance with regulatory requirements and the Community Care Fraudand Abuse Policy and Procedure. The appropriate County/Counties and oroversight entity will be notified within the same 30 day time period.j. If the audit reveals an area of non-compliance involving any issues notreflective of suspected fraud, waste or abuse, a letter will be sent to theprovider with instructions to follow regarding a corrective action plan anda directive to contact Community Care in writing within 30 business dayswith any questions, concerns, or appeals. Please refer to Policy FWA #011Provider Fraud Waste and Abuse Audit Appeal Policy for additionaldetails regarding filing an appeal.k. If the provider does not contact Community Care within 30 business dayswith any questions or concerns, it is assumed that the provider agrees withthe findings of the audit and will comply with corrective actions plans andreimbursement plans, where applicable.l. After the 30 day waiting period has passed, a copy of the letter isforwarded to the Community Care credentialing and network managementdepartments. Letters will be forwarded to the County/Counties and oroversight entities whenever the letters are sent out to the providers.m. The FWA department maintains a copy of the corrective action plan.n. The mandatory quarterly report is prepared for the BPI, the appropriatecounty, and/or the appropriate oversight entity.o. Based on results of the original audit, Community Care may conduct afollow-up audit within 3-6 months of the previous audit final disposition toreview the implementation of the Corrective Action Plan. CCBH willdocument the completion of a provider’s CAP.p. On a periodic basis the FWA Department will share audit exception trendswith the Provider Community. The audit findings will be communicatedto providers through various channels which include but are not limited toALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 6 of 8provider newsletters and FWA Department Provider Alerts. In addition,Community Care provides Fraud Waste and Abuse Provider programtrainings that are located on the website, www.ccbh.com. These trainingsinclude state, federal, and Community Care Fraud, Waste, and Abuseregulations and requirements.II. Compliance Referral Auditing Procedure1. The FWA Department accepts referrals from external and internal stakeholders.2. Like external referrals, internal referrals can be made anonymously, or can be submittedthrough the employee’s manager or director. The referral may also be reviewed by theRegional Director/Directors for the particular contract areas involved if a potential issue ofsignificance has been identified. The Sr. Director of Network Development may also bemade aware of the referral at this time.3. The FWA Department notifies the appropriate Regional Director/Directors and the Sr.Director of Network Development of external referrals that have been submitted, forexample, by member’s through our Fraud and Abuse Hotline, or by the member notifying theCare Management or Network Departments, by the Bureau of Program Integrity, or by acounty administrator of one of the HealthChoices contracts. Notification will be immediateif a potential issue of significance has been identified. For routine referrals, a monthlysummary will be provided to relevant Community Care senior management.4. Each referral is unique and therefore the details for handling the referrals vary. Forexample, if a referral is submitted by a member alleging that prescribed services are notbeing provided but they believe that their provider is submitting claims for those services,Community Care will request that the provider forward to the FWA department themember’s record in its entirety. An examination of the time period that encompasses theALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 7 of 8allegation time period will be reviewed. The amount of time reviewed will vary from referralto referral. Community Care will then compare documentation to submitted claims in orderto determine if the allegations have been substantiated. The results letter will be forwarded toFWA management for review, then the Regional Director and the Sr. Director of NetworkDevelopment for review before the letter is sent to the Provider. The Provider has 30business days from the date of the results letter to appeal in writing the decision of the audit.Please refer to Policy FWA 011 for complete details of the provider appeal process.5. If a referral is submitted to the Regional Director by the county administrator for one ofCommunity Care’s contracts, the FWA Department will consider any input given by theadministrator as to the scope of the review, and any areas of focus when conducting the audit.6. The Bureau of Program Integrity may also submit referrals directly to the FWAdepartment. The appropriate Regional Director or Directors involved as well as the Sr.Director of Network Management will be notified as necessary. The referrals from the BPImay include very specific instructions as to how the investigation should be conducted.These instructions will be followed by the FWA team.III. Monitoring of claims for suspected fraud and abuseSuspected fraud or abuse in billing and in submission of claims will be monitored by the FWADepartment through the following procedures:1. The mechanisms used for identifying suspected fraud and abuse are:• Investigation of referrals and member complaints and grievances• Chart audits conducted by the FWA Department• Collaboration with the Care Management and the Quality ManagementDepartmentsALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 8 of 82. Data mining and analysis, including claims, coding, and utilization analysis, are also usedby the FWA Department to identify suspected fraud, waste, or abuse. Community Caremay also randomly perform medical record audits of providers to monitor that servicesbilled to Community Care are substantiated by appropriate documentation.3. If the random audit reveals a pattern of discrepancies or other areas of concern that mightmeet the definition of “waste” "fraud" or "abuse", additional audit testing may beconducted and the FWA Department will notify BPI within 30 business days of suchidentification via DPW's standard referral form. The county/counties and oversightentities will also be notified by the FWA Department.4. The Director of the Community Care FWA Department will notify the appropriate countyand oversight entity, as to each instance of suspected fraud and abuse reported to BPIrelating to services under the HealthChoices contract.5. If Community Care suspects fraud, waste, or abuse by a provider that is contracted undermore than one (1) Community Care Contract, Community Care will also open aninvestigation file under the additional contract(s) and inform the appropriate authorityaccording to this policy.6. If a county oversight entity, or any county contracted with Community Care requiresadditional information at any point in an investigation, it should request it directly fromFWA management, agreeing to maintain all information as confidential.7. Community Care works collaboratively and cooperates fully with all oversight agencies,counties, and regulatory agencies including, but not limited to, CMS, DPW/BPI, theOffice of the Attorney General’s Medicaid Fraud Control Section, the U.S. JusticeDepartment, and the PA OIG.8. Community Care includes information about fraud and abuse concerns in member andprovider education materials. Along with information about how to identify suspectedALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.

POLICIES AND PROCEDURESCOMMUNITY CAREFRAUD, WASTE, AND ABUSE (COMPLIANCE) AUDITINGPOLICY AND PROCEDUREDate Issued:1/15/02Date Revised:10/01/03,11/1053/1/07;4/26/07;6/5/076/9/09,10/05/0910/15/09,10/16/09,12/20/10, 1/12/11,4/1/11Reviewed12/04;12/06;12/08Date OMHSASApproved:5/31/11Policy FWA # 001Page 9 of 8fraud and abuse, Community Care encourages members and providers to report suspectedfraud and abuse through the toll free number that is provided to them.9. Community Care’s toll free Fraud and Abuse Hotline number is 1-866-445-5190.ALL POLICIES, STANDARDS, RULES, DIRECTIVES, OR REGULATIONS CONTAINED IN THESE MATERIALS AND HOWEVER DENOMINATED,DEVELOPED, PUBLISHED OR PROMULGATED BY COMMUNITY CARE ARE PROPRIETARY AND CONFIDENTIAL INFORMATION OF COMMUNITYCARE AND ARE SUBJECT TO CHANGE, REVISION, MODIFICATION OR WITHDRAWALS BY COMMUNITY CARE AT ANY TIME WITHOUT NOTICE ANDSUBJECT ONLY TO ANY REQUIRED GOVERNMENTAL APPROVALS AS TO SUCH CHANGES OR MODIFICATIONS.