From A Desk In Tallahassee
by Kelly Bennett, NAMPI President
Warning: for those of you who are used to my writing, you probably don’t need the warning. But for everyone else it will be a bit of my long ramblings about the topic on my mind this morning. As I sit here at my desk preparing a draft of a newsletter article, I also have open on my computer the Annual MFCU-PI Survey that HHS-OIG asks us to do concerning our state’s MFCU and our interactions from the previous year. I know that these responses are considered when HHS-OIG is doing the recertification for the MFCU. In the now more than twenty years that I have been with my agency, I have been involved in our response quite a few times.
The topic of interaction with the MFCU seems odd to me. The survey is so formal (sterile) and doesn’t really seem to target the issue that I guess I think about when I am responding to it – collaboration. Isn’t the goal to assess collaboration? Maybe it isn’t. I really haven’t had that many conversations with HHS about it. This year’s survey seems even more limited – but I haven’t gone back yet to see what I wrote the last time so maybe it’s always been this way.
This article is going to be about collaboration – but maybe not in the way you think it is going to be. I wanted to share my thoughts about collaboration with MFCUs and try to get those of you who are involved in your state’s MFCU referrals to please comment in the state only forum on this topic. There will be a link to the comments at the end (of my long, rambling, article).
When I read the MFCU performance standards, particularly the one that says they are required to ensure they have an adequate workload through referrals from the single state agency and other sources, I guess I have always taken that to mean that they (MFCU) should be working with us (the single state agency) to offer us training and guidance so that our detection efforts are better able to discern when a case is abuse or waste for us to handle, or fraud, for them.
But without a sense of collaboration, at least how I understand the term, I don’t know how that gets accomplished. We (the PI operations) routinely collaborate with licensure agencies, others state and federal agencies who touch on the health care operations, federal and state law enforcement, federal health care fraud work groups, and basically anyone who will help us in our fraud fighting efforts. Maybe that’s because administratively we have pretty broad reach. A provider who isn’t following the licensure rules can be sanctioned by us; their reimbursements may be considered overpayments for us to recovery.
I have just always thought that if we, the PI folks, could get the prosecutors and investigators who are looking at fraud cases to meet more routinely with us and break down cases in that cooperative fashion that is what I think of when I think of the word collaboration, then we would be better off. All of us. They would get better cases from us.
I guess the word collaboration has always meant to me partnership and teamwork but maybe to some it is more about collusion or conspiring and is the opposite of what I think of it. I hope not. At least not to those entities we are supposed to be partnering with.
Among the questions – and questions that I think we in the PI Leadership should discuss together – are things like whether we discuss and review cases with the MFCU before an official referral is made. I think we used to at some point, years ago, but then it evolved to just making the referral because they accept them all (or almost all of them) and we will know later if they aren’t going to work it.
Another question is whether the MFCU keeps us apprised of the status and outcome of case referrals made to them us – that is a question I’d really love to have us PI Leaders talk about – what are the processes that other states have to get status reports on case. I think for us in FL we have so many cases – the volume is just overwhelming – that to some degree we don’t have time to stay on top of what we have referred to them. And when we do need to know, we can ask and get an update.
I also think it’s interesting that we get asked about factors that limit the number of referrals we make – again, I haven’t gone back to see how I answered the last time, but I can’t imagine that we’d have any limitations other than simply the resources it takes to put together the referral. And that leads me to wonder (and want us PI Leaders to sometime discuss) whether anyone still uses that old CMS guidance; it was from 2008 – you can find it on the internet if you don’t know what I am talking about. https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/Downloads/2008-Best-Practices-Medicaid-PI-Unit-Int-with-MFCU.pdf (By the way, when I was doing my research to find that old document – we use a variation of it these days so I don’t rely on it anymore – I found another document that I am not sure whether I have seen before: https://www.cms.gov/Medicare-Medicaid-Coordination/Fraud-Prevention/FraudAbuseforProfs/Downloads/fraudreferralperformancestandardsstateagencytomfcu.pdf)
This would definitely be a topic we could all discuss sometime – I think the second item I found is really just a summary of the older document because it is still asking for pretty much the same things. It may be more of a curiosity for me, I just wonder what state MFCUs really think of this. We think we know what our MFCU wants in a referral (which brings me full circle on this discussion).
If we were more collaborative and had those discussions about the cases, and the laws, and the evidence that they are looking for, we could all just do a better job at our jobs. That leads me to ask – JOIN THE CONVERSATION
- How do you get your referrals to your MFCU (not so much the mechanics but, rather, whether you send them for them to review, you meet and discuss first, whether before the referral there is any collaboration?
- How do you get updates from your MFCU on cases you have referred to them, and then what about cases you haven’t referred (how would you know not to administratively intervene with a provider if you don’t know who they are investigating)?
- What is the substance that you include in your referrals (and if you have a standard template you want to share, please upload it)?