Program Integrity

Meeting #3

Date: November 16, 2016 10:30 AM

Location: Massry Center, 1 University Place, Rensselaer NY 12144


This was the final meeting of a series of three meetings for the Value Based Payment (VBP) Program Integrity (PI) workgroup. The broad agenda for the PI Workgroup covered the following issues: (1) data quality, (2) policy design, and (3) payment integrity. Meeting #3 goals were to make a final determination on the draft recommendations from prior workgroup meeting(s) and to identify consensus recommendations on the topic of payment integrity.

The Agenda for this meeting included:

  1. Introduction
  2. Policy Design Recap & Finalization of Recommendations
  3. Payment Integrity: Issues and Considerations
  4. The Changing Landscape of Payment Integrity
  5. The Future of Payment Integrity: Develop Potential Recommendations

Key Discussion Points (reference the slide deck "PI Workgroup Payment Integrity")

1. Introduction

Jonathan Bick opened the meeting by welcoming participants and providing a recap of progress made by this workgroup to date. Participants were made aware that the focus of this meeting would be payment integrity and the majority of the time would be spent framing the policy question and sub–questions, followed by a roundtable discussion and development of consensus recommendations. Depending on the level of progress made during the meeting, a decision would be made as to whether this group would reconvene by phone to finalize any outstanding recommendations or whether soliciting comments via email would suffice.

2. Policy Design Recap & Finalization of Recommendations

Participants were reminded of the distinction between policy design and payment integrity; policy design was described as the "what" and payment integrity was described as the "how". Participants were also encouraged to continue to submit written feedback on the draft recommendations distributed previously. The co–chairs emphasized that the comments on these draft recommendations received thus far did not change the substance of the recommendations, but rather clarified the true intent of each of these topics. It was noted that while this group is responsible for finalizing recommendations on the topic of program integrity, the Department of Health (DOH) would ultimately finalize the recommendations. The group began a discussion to modify the previously distributed draft recommendations to allow for policy design under VBP. Fully vetted recommendations will follow this meeting.

3. Payment Integrity: Issues and Considerations

The co–chairs described payment integrity as an existing concept, however noted that the introduction of VBP presents new avenues for fraud, waste, and abuse and necessitates a new approach to payment integrity efforts. Payment integrity was broadly defined as the control of fraud, waste, and abuse within the context of program integrity. It also includes any act that constitutes fraud under a federal or state law. Workgroup members used their expertise to elaborate on these definitions. Fraud encompasses intentional acts and in this context knowledge is defined as "deliberate ignorance and reckless disregard". Abuse also includes beneficiary practices which result in unnecessary costs to the Medicaid program.

4. The Changing Landscape of Payment Integrity

Throughout the transition to VBP, participants clarified the importance of encounter data under both the fee–for–service and VBP payment arrangements.

5. The Future of Payment Integrity: Develop Potential Recommendations

The workgroup spent the remainder of the session discussing policy questions relevant to payment integrity in an effort to develop draft recommendations to issue to the VBP Regulatory Subcommittee and DOH.

Policy Question A: What are the broad Program Integrity Issues that manifest themselves through VBP with regard to partner agencies? What changes need to be made in response to these issues?

From the Office of the Medicaid Inspector General´s (OMIG) perspective, VBP is novel and at the stage where they are not entirely sure what will relationship or infrastructure changes will happen. Participants from OMIG stressed the need for strong guidance, guidelines, and policies in order to be successful with their payment integrity efforts moving forward. OMIG provided that these strong policies and guidelines will help to ensure that there is an even playing field through VBP and that providers and plans must be notified what expectations will be imposed on them. OMIG also stressed the importance of data systems and repositories that will lend themselves to regulatory oversight. In conjunction with these systems, procedures for self– auditing and monitoring should also be developed and were stressed by OMIG. While OMIG has made some changes to their internal procedures due to VBP and are in the process of implementing additional changes in relation to plans, from OMIG´s perspective it is too early to know how OMIG will further adapt to VBP. In terms of developing these policies, OMIG representatives described the process of distributing proposed protocols to associations and allowing for a comment period before posting finalized protocols to their website. OMIG noted that their representatives also have regular conversations with partner agencies about interpretations, needs, etc. While there is an inherent relationship between program agencies and OMIG, these relationships have largely been unstructured up to this point and standardization would benefit all parties.

From the perspective of the Office of Alcoholism and Substance Abuse Services (OASAS) and the Office of Mental Health (OMH), participants stressed the fact that there is a tendency to operate in silos, but that OASAS and OMH do have limited interaction with other agencies. OASAS and OMH representatives stressed that the shift to managed care has been material. Under VBP, it was noted that providers will again experience through changes in the way they are paid as well as the protections and provisions that are in place to facilitate their work.

It was noted that the metrics underlying all material aspects of VBP need to be quantified and shared with all relevant stakeholders. The workgroup noted that the agencies impacted by VBP need to know what they are supposed to be auditing. To do so, a recommendation was made to ensure that NYS agencies come together to share information and best practices on a regular basis.

The Medicaid Fraud Control Unit (MFCU), noted that their core work of doing investigations will not change as a result of VBP. MFCU noted that the biggest challenge they encounter is the lack of an auditable trail. MFCU has always needed encounter data in order to build and support cases. MFCU noted that this is further complicated by delays in claims submission from providers to plans. Under the current system MFCU requires timely claims data, but notes that there are long delays in provider claims submissions. MFCU noted that this will materially delay any integrity assessments related to VBP. Anecdotally, MFCU shared that they see cases where providers have taken advantage of delaying data submission. To this effect, MFCU requested that a recommendation include a 90 day maximum for the submission of encounter data.

Policy Question B: Where should accountabilities for payment integrity responsibilities lie in relation to Medicaid Program Integrity?

Stakeholders stressed that many aspects of VBP are too new to tell where changes will need to be made. Instead, time will need to be allocated to studying the new system before recommendations can be developed. To this effect, stakeholders felt that a recommendation should be developed that allows PI agencies a period of time to develop a forward–looking lens. In the interim, state agencies should be encouraged to make public what policies and infrastructure are under development.

Workgroup participants felt that front end infrastructure focused on the prevention of fraud, waste, and abuse was important. Similarly, it is important to look closely at the infrastructure of community based organizations (CBOs) and their capacity to adhere to all of the compliance and risk management rules that will be newly imposed upon them under VBP. A significant number of small organizations will be billing Medicaid for the first time and there is a lack of clarity on how well equipped they are with the right data systems and resources in place to successfully operate under VBP. State agencies currently monitor the fiscal viability of CBOs, and some CBOs have compliance programs. However, not all currently have mandated compliance programs and those entities will need assistance with implementing their respective programs and navigating the existing restrictions associated with such programs (e.g., the requirement that the compliance officer be a W2 employee of the organization).

Another recommendation was made that an educational infrastructure be put in place to help agencies develop their respective guidelines under VBP. Similarly, incentives can be put in place to encourage collaboration between plans and providers around issues related to PI. Another recommendation was made that all organizations and individuals providing services related to the Medicaid program be registered as Medicaid providers to ensure that they have a better understanding of their expectations and requirements.

While OMIG feels that dialogues with providers to date have been open and comprehensive, the learning process is ongoing and collaborative audits provide a good opportunity for mutual learning. In an effort to be proactive with program integrity efforts, learnings related to these audits should be recycled back to plans, providers, and enforcement organizations.

Ultimately, stakeholders felt that it was too soon to know many of the changes that would need to be put in place to adequately respond to payment integrity efforts under a VBP system. Potential recommendations include agency alignment, giving oversight agencies time to develop thoughts and recommendations around the future of PI, and circulating lessons learned among entities–both internal to the state and external–impacted by VBP.

Policy Question C: How can New York State (NYS) determine whether the existing policies, laws, and regulations are adequate to allocate responsibility for payment integrity enforcement among stakeholders?

Stakeholders felt strongly that no laws should be changed as a result of VBP, nor should the strength of NYS statutes be decreased. Under VBP, agencies are not rolling back the ability to enforce and monitor, but the act of sharing ventures should potentially be more permissible.

Materials distributed during the meeting:
Document Description
PI Workgroup – Payment Integrity A presentation deck of policy questions and options for payment integrity as it relates to VBP program integrity.
Key Decisions

The Workgroup made decisions on the following key points during meeting #3:

  • ✓ Draft recommendations would be vetted by the co–chairs and circulated amongst the workgroup for written comments following this meeting.
  • ✓ After workgroup participants are able to submit feedback and have signed off on the consensus recommendations, the DOH will be responsible for the implementation of these recommendations.
Action Items:
  • KPMG to facilitate with the aggregation of proposed recommendations, co–chair review, and solicitation of workgroup comments.

This meeting concluded the series of three Program Integrity workgroup meetings.