CARLA ENGLE, MBA

Monday, 04/27/09

Monday proved to have many great sessions that continued the Medicare/Medicaid benefit integrity education.  Daniel Levinson, the Inspector General of HHS, started the morning during the General Session, followed by Kim Brandt, the Director of the Program Integrity Group of CMS, giving an overview of CMS and its Program Integrity activities, including some tips in handling ZPIC and RAC transactions.

Several afternoon sessions continued to address government payor hot topics: Ready or Not, Here They Come! Preparing for and Defending RAC Audits by Andrew Wachler, Esq., Wachler & Associates, P.C. and Jennifer O'Brien, Esq., Halleland Lewis Nilan & Johnson, Implementing an Integrity Compliance Program in a Multi-State Non-Profit by Mark Sawyer, CHC, Youth Advocate Programs, Inc. and Steve Kohler, CHC, McBee Associates, Inc. and New York State: Medicaid Managed Care Compliance Landscape by Regina F. Gurvich, MBA, CHC, Director of Compliance, Health Plus PHSP and Robert Hussar,  Director of Compliance First Deputy Medical Inspector, Health Plus PHSP State of New York, Office of the Medicaid Inspector General.

Below are some highlights of the outlines of each session, including links to the handouts of the presentations:

Monday, 04/27/09, 9:00-9:45

Integrity and Health Care Reform: The Charge to Government and Industry

Daniel R. Levinson, Inspector General, US Department of Health and Human Services

http://www.compliance-institute.org/pastCIs/2009/PDFs3page/Monday_GS_Levinson/Monday_GS_Levinson.pdf

Summary:

1)      Health Care Policy Landscape

a)      Health care reform

i)        Priority of Administration and Congress

ii)       Economy - financial strains, health care investments

b)      Accountability and transparency

i)        OIG roles - Recovery Accountability and Transparency Board

ii)       Roles of compliance professionals

2)      OIG's 5-Principle Strategy for Health Care Integrity to Combat Healthcare Fraud, Waste, and Abuse:

1. Enrollment: Scrutinize provider applicants

2. Payment: Use reasonable, responsive methods

3. Compliance: Assist providers to comply

4. Oversight: Monitor for fraud, waste, abuse

5. Response: Punish fraud, remedy vulnerabilities

3)      Conclusion and Resources

4)      OIG resources available online at: http://oig.hhs.gov

• Exclusions Program and LEIE
• Compliance Resources - Compliance Program

Guidance, advisory opinions, roundtable summaries

• Self-Disclosure Protocol and Open Letters
• OIG work plan
• Audit and evaluation reports

Monday, 04/27/09, 9:45-10:30

General Session: Hedging Your Bets: Following the Rules of CMS Compliance

Kim Brandt, Director Program Integrity Group, CMS

http://www.compliance-institute.org/pastCIs/2009/PDFs3page/Monday_GS_Brandt/Monday_GS_Brandt.pdf

Summary:

1)      Overview of CMS' FFS contractors

a)      Program Integrity Group

i)        "Program Integrity" refers to all CMS programs      aimed at:

(1)   Detecting and preventing fraud in the Medicare fee-for-service, Medicare Advantage and Part D programs.

(2)   Ensuring the integrity of the Medicare fee-for service enrollment process.

(3)   Promoting compliance with Medicare rules.

b)      Contractors

i)        Zone Program Integrity Contractors (ZPICs)

(1)   Seven zones based on MAC jurisdictions

(a)    Five "hot spot" zones

- California, Florida, Illinois, New York and Texas

- "Hot spots" align with Program Integrity field offices

- Focus on quick response to fraud and administrative actions

- Reduce emphasis on fraud referrals as law enforcement does not have the resources to accept them

(b)   Two other zones

- 24 states with limited incidence of fraud

- Continue using proven PSC processes

(c)    To prepare for the transition from PSCs to ZPICs, providers should continue to submit claims appropriately.

(d)   ZPICS - Benefits of the Strategy

(i)      Strategy achieves best value for CMS by leveraging economies of scale and concentrating in high fraud areas

(ii)    Increased efficiency to look at providers across all benefit categories

(iii)   Economies of scale through the consolidation of contractor management, data/IT requirements, facility costs, etc.

(iv)  Streamline CMS costs in acquisition, management and oversight

(v)    Better coordination and less resources required for the States

(vi)  Increased security of PHI due to fewer contractors handling the data

(e)    ZPIC Awards

(i)      Both Zone 4 and Zone 7 were awarded on September 30, 2008 and transitions began immediately.

(ii)    Zone 4 was awarded to Health Integrity LLC, a current Part D Medicare Drug Integrity Contractor.

(iii)   Zone 7 was awarded to SGS, the incumbent Program Safeguard Contractor for Part A and B benefit integrity functions.

(iv)  Both became fully operational -- which means the zones will be handled by a ZPIC rather than a PSC, on February 1, 2009.

(v)    Cycle 2 (Z ones 1 and 2) procurement is ongoing. No awards have been made.

(vi)  Cycle 3 (Zones 3 and 6) has not yet been released.

(f)     ZPIC and MAC Operations

(i)      Will there be any differences in the relationships between ZPICs and MACs as compared to the relationships between PSCs and the contractors?

-        Both ZPICs and MACs are now required to have dedicated liaisons for the other contractor, i.e., the ZPIC has a MAC Liaison and the MAC has a ZPIC Liaison.

-        Note: the liaison is not necessarily full-time, but it is a single person who consistently fills this role.

-        We anticipate that this position will enhance the interaction and communication between the ZPICs and MACs.

(g)    Role of PSCs /ZPICs

- Ensure that fraudulent or abusive behavior against the Medicare   program is identified and corrective action is taken.

- Serve as a law enforcement liaison to ensure coordination on cross-cutting issues.

- Impose Administrative Actions such as suspensions, overpayment collections, referrals or sanctions.

- Identify, monitor and track fraud, waste, and abuse in Medicare through data analysis.

- PSCs/ZPICs also conduct a significant amount of data analysis to supporting requests for information by law enforcement.  These activities support cases which are going to trial or settlement negotiations.