Ann & Natalie’s Compliance Corner
This month, we present new guidance available to practices to help avoid fraud, waste and abuse charges within Medicaid. Missed last month’s article on privacy considerations with physician blogs? Click here.
The Centers for Medicare and Medicaid Services (CMS) released a document on July 20, 2007 that provides valuable information for your practice on Medicaid’s initiative to intensify review and enforcement in the years ahead.
This new request for proposal (RFP) document is intended to provide guidance to potential Medicaid Integrity Contractors (MICs) and outlines the types of fraud, waste, and abuse that should be reported within the Medicaid program.
Under section 6034 of the Deficit Reduction Act of 2005 (DRA), CMS is responsible for implementing the Medicaid Integrity Program (MIP). The main objectives of the MIP are:
- Review the actions of individuals or entities furnishing items or services for fraud, waste, or abuse;
- Audit claims for payment for items or services furnished, or administrative services rendered; and
- Identify overpayments to individuals or entities receiving federal funds under this title.
The RFP also highlights the specific MIP functions that would be required of MICs as part of this initiative and includes:
- Preventing and/or detecting Medicaid fraud, waste, and abuse;
- Decreasing any submission, processing, or payment of inappropriate Medicaid claims;
- Recommending appropriate administrative action to ensure appropriate and accurate payments for Medicaid services; and
- Recommending leads to MICs for auditing claims and services that potentially constitute inappropriate payments identified through reviews.
The RFP requires MICs to coordinate with various agencies that perform these tasks to ensure an efficient review of information and to increase provider awareness. The MICs will assess Medicaid claims data by gathering and analyzing information as well as by performing risk assessments. MICs will have access to existing state database systems to perform their work.
Since the RFP indicates that the sole job function of these contractors is to identify and report any suspected incidents of waste, fraud, or abuse, it is apparent that MICs will intensify their review of Medicaid claims in an effort to report potentially improper provider activity. It is also likely that these enforcement activities will be strictly pursued given the fact that there is a required coordination clause with agencies such as the DOJ, FBI, and OIG.
The RFP provides a valuable resource for providers to identify and resolve any areas of concern and to ensure that their actions are in compliance with the requirements of the MIP. Providers should ensure that they monitor further issuances of RFPs by CMS for more details regarding increased Medicaid enforcement initiatives mandated by the government.
Disclaimer: The content of Compliance Corner is for general informational purposes only and should not be interpreted as compliance guidance or advice. Consult your compliance advisor or attorney for compliance or legal advice on specific issues related to your practice or compliance program.
