Always Reppin’ – Region VII
Kimee Pierson (IA), Corey Richmeier (KS), Dale Carr (MO), and Anne Harvey (NE)
Greetings to our NAMPI colleagues from Region VII, consisting of the “flyover states” of Iowa, Kansas, Missouri, and Nebraska. As of the writing of this article, Mother Nature has not yet given us a full reprieve from the cold winter weather. We get teased with an occasional sunny and 75-degree weekend before the wind swings around and brings us another blast of cold wind and moisture from the northern regions.
We hope you have been able to stay warm and safe from COVID and Influenza A, which have also been slow to fade away.
From the Medicaid program integrity standpoint, the COVID public health emergency (PHE) has presented numerous challenges. Virtually every state and territory sought CMS and state executive authority to grant flexibilities in the delivery of healthcare services and the corresponding documentation requirements. Monitoring the numerous flexibilities to determine if they have expired or been extended is a demanding chore. Some of the flexibilities granted at the state executive level have ended, while most of the flexibilities granted by CMS have been extended and/or are still effective up to six months after the expiration of the declared PHE.
In many states, providers and/or their professional associations have been lobbying for certain flexibilities to be made permanent. While that might make sense in some cases, the flexibilities frequently relaxed previously required face-to-face meetings between healthcare professionals and Medicaid participants, along with signature requirements to verify billed services were received. Making the flexibilities permanent do not necessarily go hand-in-hand with our program integrity efforts.
In our region, we monitored the billing patterns of enrolled providers in an attempt to identify situations where there should have been a decrease in billing, especially during the early months of the COVID PHE, when most states implemented mandatory “stay at home” orders. I’m sure everybody remembers that many providers basically shut down during the stay-at-home periods and you couldn’t even get a routine appointment to see a dentist, optician, counselor, or physical/speech/occupational therapist.
In Missouri, we paid a lot of attention to the claims submitted by Adult Day Care (ADC) providers. We noted there were a number of providers that continued to bill at the level they were billing before the COVID PHE and stay-at-home orders started. Although Missouri granted certain flexibilities for ADC services to be provided as a respite at the participants’ homes, it had to be prior authorized as respite and provided by a paid employee of the ADC who had been through the normal pre-employment screening processes.
After identifying a number of ADCs with suspicious billing patterns, investigations were initiated to collect documentation and interview their owners, employees, and Medicaid participants. Missouri investigators ended up finding a “credible allegation of fraud” in about five cases that were referred to the Medicaid Fraud Control Unit (MFCU). As suspected, the owners of those ADCs were billing Medicaid for services that were not provided. The average amount of fraudulent billing identified during audits and investigations of ADC providers was $97,685. The improper billing ranged from $7,498 to $285,777. The identified amounts were for the initial review period. After the MFCU accepts a fraud referral, they usually expand the scope of the investigation to include additional dates of service.
Another hot topic in our region has been the expanded use of Electronic Visit Verification (EVV) for in-home Personal Care Services (PCS) and Home Health Care Services (HHCS). Although EVV was required by the 21st Century Cures Act to be fully implemented by January 1, 2020, some states were granted a “Good Faith” exception or waiver by CMS to delay full implementation until January 1, 2021.
Some states have a closed model where there is only one EVV vendor that all PCS providers are required to use. Some states use an open model, where PCS providers can choose from a list of certified or approved EVV vendors. Regardless of which model a state chooses, the current challenge is to: (1) Establish for CMS that all Medicaid PCS providers are using EVV for 100% of their authorized participants; (2) that the providers and EVV vendors are capturing all required data components, and (3) that the EVV data from each provider is being properly uploaded into an EVV Aggregator solution. The electronic aggregator solutions (EAS) allow folks like us to determine whether the uploaded EVV data matches the PCS claims being submitted for payment. Most aggregator solutions have FWA dashboards that flag occurrences when a PCS attendant is clocked in for more than one Medicaid participant at a time are outside a pre-set distance radius from the participant’s residence, or even in a different state. Yes, it really does happen!
Our region is interested in sharing information regarding getting PCS providers in full compliance with the federal requirements, particularly any experiences regarding imposing payment or participation suspensions on non-compliant providers.
In closing, we are looking forward to the annual NAMPI conference to be held in Baltimore, MD, from August 7-10, 2022. We are pleased that attendees will have the choice of attending in-person or virtually. We know the NAMPI board has been hard at work planning for an excellent conference and we look forward to seeing you there.
Best regards from the Region VII PI Directors – Kimee Pierson (IA), Corey Richmeier (KS), Dale Carr (MO), and Anne Harvey (NE).