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2020 Annual Report

The Utah Office of the Inspector General (UOIG) submitted its 2020 Annual Report to the Governor, Speaker of the House, Senate President and to the Executive Appropriations Committee. This is the tenth fiscal year that the UOIG has conducted oversight operations of the Medicaid program. For 2020, the Office recovers funds through three methods: cash collection, OIG directed rebilling of claims and credit adjustments.

Recovery of improperly paid Medicaid funds serves purposes beyond simply bringing funds back into the program. The Office considers recovery of funds a “sentinel event” that many times changes a provider’s future billing practices. In that sense, recovery of funds acts as an educational tool with a correlating cost avoidance amount. During SFY 2020, the Office collected a total of $9,565,485 through all three methods of recovery. This recovery amount was above the Inspector General’s forecast of $3-5 million during an average year. The $3-5 million recovery is the average recovery amount for States of similar size and Medicaid covered population. UOIG saved the state an additional $21 million in cost avoidance attributable to the actions taken by UOIG, including recommendations to the Single State Agency that cause positive change in the program. The full UOIG 2020 Annual Report is available on the Office’s website and by clicking on the following link

HHS OIG List of Excluded Individuals and Entities (LEIE)

The LEIE has been updated on 06 August 2020 with July 2020 Exclusions and Reinstatements. As a reminder, HHS OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances. Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, health care entities need to routinely check the LEIE to ensure that new hires and current employees are not on the excluded list. Utah Medicaid Providers must review the updated LEIE in accordance with federal law and Utah Medicaid policy. The LEIE is located at: https://oig.hhs.gov/exclusions/exclusions_list.asp

2019 Annual Report

The Utah Office of the Inspector General (UOIG) submitted its 2019 Annual Report to the Governor, Speaker of the House, Senate President and to the Executive Appropriations Committee. This is the ninth fiscal year that the UOIG has conducted oversight operations of the Medicaid program. For 2019, the Office recovers funds through three methods: cash collection, OIG directed rebilling of claims and credit adjustments. Recovery of improperly paid Medicaid funds serves purposes beyond simply bringing funds back into the program. The Office considers recovery of funds a “sentinel event” that many times changes a provider’s future billing practices. In that sense, recovery of funds acts as an educational tool with a correlating cost avoidance amount. During SFY 2019, the Office collected a total of $4,653,957.21 through all three methods of recovery. This recovery amount is consistent with the Inspector General’s forecast of $3-5 million during an average year and consistent with recoveries achieved by States of similar size and Medicaid covered population. An additional $18 million was protected from inappropriate expenditure through a concept known as “Cost Avoidance.” These Cost Avoidance and Collections measures resulted in a combined return on taxpayer investment of 760.41% or of every $1 spent $7.60 was saved. The full UOIG 2019 Annual Report is available on the Office’s website and by clicking on the following link. For more information and media inquiries, please contact UOIG at (801) 538-6532.

Utah Voters Pass Medicaid Expansion

Utah voters approved for a full Medicaid Expansion on Tuesday November 6, 2018. Voter approved full expansion replaces the plan that was passed by Utah lawmakers earlier this year to limit Medicaid expansion with a work requirement. The limited Medicaid expansion required a waiver and federal governmental approval because of the work requirement and that it limited expansion specified in the Affordable Care Act. It is anticipated that full Medicaid will cover adults with annual incomes up to 138 percent of the poverty level and it is estimated that the expansion will cover up to 150,000 more people. Utah now joins more than 30 others states that have expanded Medicaid under the 2010 health care law.

Cost Avoidance? What is it and how is it determined.

During SFY 2018, the Utah Office of Inspector General’s (UOIG) management team and their data scientist developed a cost avoidance methodology that captures changes in provider billing behavior as well as impacts of less tangible Office activities like audit recommendations and training.

The Inspector General defines cost avoidance, as any action the Office takes that will reduce Medicaid costs in the future.

The cost avoidance methodology establishes a baseline to determine the changes that occur after a sentinel event. The UOIG calculates the baseline by first, determining how much the procedure or policy is costing the Medicaid program over a specified period, usually no more than 36 months. The Office then takes some action (sentinel event) and monitors the baselines for changes in trends. The Office then calculates the difference between pre and post event to calculate cost avoidance.

The Office usually observes trends over an equal amount of time pre and post event and forecasts cost avoidance no more than three years into the future. During the post event period, the Office monitors the trend lines for changes. This step is necessary since new policy or new providers can cause the previous behavior to resurface.

The following example illustrates the UOIG’s cost avoidance methodology:
Providers use Bilirubin Lights as in-home treatment for jaundice, most often in newborns. When the UOIG reviewed policy that outlined the use of Bilirubin lights they discovered providers left the lights in homes longer than necessary and billed for that additional time. The Office conducted three reviews of bilirubin lights and recovered approximately $70,000 dollars. Prior to the UOIG’s review there were 12,400 claims submitted over a three-year period to Medicaid, equaling $652,288. After the review, the claims dropped to 1478 over the subsequent three years and cost the state $240,704. The Office’s action resulted in a behavioral shift of $411,584 and resulted in annual savings to the Medicaid program of $137,194 or $411,584 projected over three years. The Office continues to monitor bilirubin lights and the behavioral change remains consistent. However, if there was a spike in claims submitted for the lights the Office could conduct an audit to determine the cause.

2018 Annual Report

The Utah Office of the Inspector General (UOIG) submitted its 2018 Annual Report to the Governor, Speaker of the House, Senate President and to the Executive Appropriations Committee. This is the eight fiscal year that the UOIG has conducted oversight operations of the Medicaid program. For 2018, the UOIG successfully collected $1,423,963 through cash collection, $1,327,266 through rebilled claims, and $743,315 through offsets. An additional $14 million was protected from inappropriate expenditure through a concept known as “Cost Avoidance.” These Cost Avoidance and Collections measures resulted in a combined return on taxpayer investment of 474% or of every $1 spent $4.74 was saved. The full UOIG 2018 Annual Report is available on the Office’s website and by clicking on the following link. For more information and media inquiries, please contact UOIG at (801) 538-6532.

HHS OIG List of Excluded Individuals and Entities (LEIE) Updated for October 2018

The LEIE has been updated on 09 November 2018 with October 2018 Exclusions and Reinstatements. As a reminder, HHS OIG is required by law to exclude from participation in all Federal health care programs individuals and entities convicted of the following types of criminal offenses: Medicare or Medicaid fraud, as well as any other offenses related to the delivery of items or services under Medicare, Medicaid, SCHIP, or other State health care programs; patient abuse or neglect; felony convictions for other health care-related fraud, theft, or other financial misconduct; and felony convictions relating to unlawful manufacture, distribution, prescription, or dispensing of controlled substances. Anyone who hires an individual or entity on the LEIE may be subject to civil monetary penalties (CMP). To avoid CMP liability, health care entities need to routinely check the LEIE to ensure that new hires and current employees are not on the excluded list.

Utah Medicaid Providers must review the updated LEIE in accordance with federal law and Utah Medicaid policy. The LEIE is located at: https://oig.hhs.gov/exclusions/exclusions_list.asp

Successful OIG-Medicaid Provider Training Series

Utah Office of Inspector General (UOIG) partnered with Utah Medicaid to participate and present the 2018 Statewide Provider Training webinar. A total of six webinar sessions were presented for the Utah Medicaid community, with a combined 423 participants in this year’s annual training series. Topics presented included: Provider Enrollment; Medicaid 101; What’s New; Prior Authorization; and UOIG.

For the UOIG, we discussed and presented material about the oversight mission of the office, trends in fraud, waste and abuse, lessons learned and guidance on the prevention of improper payments within the Utah Medicaid program.

Providers and other interested persons are invited to contact UOIG to request additional training related to oversight of Medicaid and how to report suspect fraud, waste and abuse within the program. For more information about the UOIG, to request training or to report suspected improper payments, please contact us at 801-538-6087, online at https://oig.utah.gov or by email to mpi@utah.gov.”

Medicaid Provider Training Webinar – 2018

Utah Medicaid is hosting provider training through an online webinar format. The Utah Office of Inspector General is participating in these webinars and will present a section about oversight of the Medicaid program. Providers may register for one of the available webinars at: https://goo.gl/dXN2Y5. The next available webinar dates are: May 10, 11, 17 and 18.

Providers are encouraged to participate in this webinar to learn more about the following 5 topics:

1. Provider Enrollment (including PRISM);
2. Medicaid 101 and Managed Healthcare Updates;
3. Prior Authorizations;
4. What’s New at Utah Medicaid; and
5. Office of Inspector General Overview.

PRESS RELEASE: PROTECTING UTAH MEDICAID RECIPIENTS, ENFORCING POLICIES AND DEVELOPING PARTNERSHIPS

SALT LAKE CITY – The Utah Office of Inspector General of Medicaid Services (Utah OIG) was created to protect the Utah Medicaid program through a variety of oversight operations such as auditing, investigations, inspections, monitoring, training and reviews of Medicaid policies. These oversight activities are intended to protect Utah taxpayers by ensuring providers follow established policies and by maximizing the efficient operation and management of the program. The Utah Medicaid program is an important resource to Utah that provides health care to vulnerable low income populations to include pregnant women, children, elderly, disabled, qualified parents and women with breast or cervical cancer.

During 2017, Utah OIG Investigator Kristan Hernandez instituted focused investigations into the proper billing of Medicaid patients to ensure these vulnerable populations were not improperly billed by providers. To help offset the cost of providing health care, some Medicaid recipients are required to pay cost-sharing amounts such as co-payments. These amounts are typically low, but can be a significant burden on a low income patient. Investigator Hernandez, during her “balance billing” focused investigations, discovered that a small number of Utah Medicaid patients were balance billed for amounts not authorized by policy. One patient was billed as much as $813 when there was no cost-sharing requirement associated with the service. The investigator learned that when some patients could not pay the bill, their account was turned over to collection. This compounded the financial burden on patients with the incurrence of attorney’s fees, costs and interest.

Investigator Hernandez discovered 15 Utah Medicaid providers that have balance billed some patients in violation of policy. During these investigations, Hernandez realized the majority of the providers simply did not understand that Medicaid policy prohibits balance billing. Providers overwhelmingly welcomed the opportunity to better comply with policies and quickly rescinded collection efforts. The investigations resulted in protection of Medicaid patients and the program through better education and awareness for providers. “Utah Medicaid providers want to be good partners to the program and want to comply with Medicaid policies. They have worked hard to correct any billing mistakes and have been open to receiving further training to stay strong partners to the program and community,” says Investigator Hernandez. When Utah OIG determines a provider could benefit from training, they are referred to the Policy & Training Coordinator who works with the providers to schedule and present training about Medicaid policy and operations of the Utah OIG.

As the result of these focused investigations, the Utah OIG has determined that balance billing is an increasing issue that negatively impacts recipients and the program. Utah OIG will continue to identify policy violations to protect recipients, the Medicaid program and taxpayers of Utah.

To learn more about Utah OIG, please visit us at https://oig.utah.gov or contact our Public Information Officer at (385) 831-5397.

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