illinois_oig_self_disclosure_protocol_for_self_reporting_medicaid_overpayments_4830.html

Nick LynnThe Illinois Department of Healthcare and Family Services ("Department"), Function of Inspector General ("OIG"), has at present issued an Informational Notice and Voluntary Provider Cocky-Disclosure Protocol ("Protocol") providing Medicaid providers a mechanism to notify and repay the Section in the upshot of a Medicaid overpayment. Although the federal government has had a self-disclosure protocol in identify regarding Medicare overpayments, this is the first Protocol issued past the Section pertaining to Medicaid overpayments.

The federal Patient Protection and Affordable Care Act ("ACA") requires providers to timely identify and repay Medicare and Medicaid overpayments. Under the ACA, providers are obligated to report, explain, and repay overpayments within sixty agenda days of "identification." Providers failing to disclose, explain, and repay the overpayment in a timely manner may be subject to liability under the federal Fake Claims Act, amid other federal and Land laws.

According to the Department's OIG, the following benefits may exist extended to Medicaid providers which participate in a self-disclosure in practiced-organized religion:

  • Forgiveness or reduction of involvement payments (for up to two years);
  • Extended repayment terms;
  • Waiver of some or all applicable penalties and/or sanctions;
  • Timely resolution of the overpayment
  • Decreased likelihood of imposition of an OIG corporate integrity understanding ("CIA"); and
  • If made within 60 days of identification, avoidance of False Claims Acts penalties.

A Medicaid provider may utilize the Protocol after information technology fully investigates and confirms that an overpayment exists, or that billings were submitted erroneously even if no overpayment occurred. Importantly, cocky-disclosure of an overpayment must exist made within threescore days of the overpayment being identified or the date that any corresponding Medicaid cost report is due, if applicative. Failure to report the overpayment in a timely manner subjects the overpayment claims to false Claims Act penalties ($v,500 to $eleven,000 per merits plus three times the amount of damages).

The Protocol is non intended to be used for minor or insignificant matters such equally the repayment of elementary occurrences of overpayment(s) (on which the Department did not elaborate). According to the Department, repayment of simple overpayments should typically exist handled through traditional resolution methods such equally voiding or adjusting the amounts of claims. The Department's OIG encourages providers to utilize the Protocol when circumstance warrant. Items which are appropriate for self-disclosure may include, but are not limited to:

  • Substantial routine errors;
  • Systematic errors;
  • Patterns of errors; and
  • Potential violations of Country and federal laws and regulations relating to the Medicaid program, such every bit noncompliance pertaining to documentation and records, quality of intendance, price reports, and their party liability.

Once a provider determines that cocky-disclosure to the Department's OIG is advisable, it should ready a written Disclosure Report with the following information, where applicable:

  • Provider information, including name (including doing business as proper noun, or starting time, heart, and last name), Medicaid provider identification number, license number, NPI, DEA number, business address, mailing address, phone number, fax number, and e-postal service address;
  • Contact person, if not the provider, and contact information. Specify the relationship of the contact person to the provider;
  • The ground (or bases) for the disclosure, including the guess fourth dimension menses covered and an assessment of the potential financial impact;
  • Citations to the specific State and federal Medicaid program laws, regulations, rules, policies, guidance, Department Handbook provisions, and/or other authorities that are or may be implicated;
  • A password protected or otherwise secure Excel or MS Access file on CD with a detailed listing of claims paid or submitted that comprise the overpayments. Each claim should list the Medicaid provider identification number, recipient names, Recipient Identification Number, engagement(s) of service, process code(south) billed, and the amount(southward) paid by the Department;
  • For identification purposes, the file(due south) on the CD must exist named in accordance with the post-obit format: NPI Number_SelfD_SubmittingDate. extension (xls/mdb). For example: 1234567890_SelfD_03012 013.xls (Excel) or 1234567890_SelfD_03012013.mbd (MS Access);
  • Any law enforcement, State, and/or federal agency that has been notified of the aforementioned conduct. Include the name, championship, and contact information of notified individuals, and the date of notification;
  • The nature and extent of whatsoever investigation or audit conducted by the provider to place and determine the corporeality of the overpayment;
  • A summary of the identified underlying crusade of the upshot(s) involved and whatsoever corrective action taken, the engagement the correction occurred, and the process for monitoring the outcome to preclude reoccurrence;
  • The names of individuals involved in any suspected improper or illegal conduct and whether they are nevertheless employed by or otherwise affiliated with the provider;
  • An testament of accurateness and completeness of the Disclosure Report, signed by the provider (if an private) or an unauthorized individual (if an arrangement).

The Disclosure Report (including the CD) is to be submitted by mail service to the following address:

The Illinois Department of Healthcare and Family unit Services
Office of Inspector Full general c/o Self-Disclosure Protocol
Attention: Trish Phillips, Chief of Staff
404 5th Street
Springfield, Illinois 62763

Upon receipt of the Disclosure Report, the Department's OIG volition consider each disclosed incident on an private footing, and will consider the following factors, among others:

  • The exact issue(due south);
  • The dollar amount involved;
  • The percent of the provider'southward overall Medicaid reimbursement involved;
  • Any patterns or trends;
  • The flow of non-compliance;
  • Timely employ of the Protocol;
  • The circumstances that led to the non-compliance;
  • The provider'southward history with the Section, including recurring overpayments for the same reason; and
  • Whether the provider has a CIA in place.

Upon review of the provider's Disclosure Report, the Department's OIG may independently conclude that the matter warrants referral to the Illinois Attorney General's Medicaid Fraud Command Unit and/or other regime. In the upshot that the provider and the Department'south OIG cannot reach agreement on the corporeality of the overpayment, or if a provider fails to cooperate in good faith, the OIG may pursue the thing through established audit or investigation processes; and the possible advantages of self-disclosure, such as less stringent repayment and/or sanction terms, may no longer apply.

Matters related to an ongoing department audit of the provider are not generally eligible for resolution under the Protocol. If the OIG is already auditing or investigating the provider, and the provider wishes to avail itself of the Protocol, it should bring the matter to the attention of the assigned auditor and make a submission under the Protocol. The OIG will not have any payment for self-disclosures every bit full and terminal payment prior to finalizing its review and verfication process. In one case a repayment amount has been agreed upon between the Section'due south OIG and the Medicaid provider, the OIG expects the provider to reimburse the Country of Illinois for the overpayment with payment in total or to enter into a repayment agreement if repayment was not previously made. Upon closure of a matter, the OIG will consequence settlement documentation.

Reprinted past permission.