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 Providers overwhelmingly welcomed the opportunity to better comply with policies and quickly rescinded collection efforts.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.

Utah law provides for disciplinary measures and sanctions for Medicaid providers that do not follow rules or procedures of the program. Reasons for a sanction may include submitting fraudulent claims, false information to receive a higher payment or prior authorization, failing to maintain records necessary to substantiate services, failing to disclose records, breaching terms of the provider agreement, inducing patients to receive services not medically necessary, giving or receiving rebates for referrals, substandard services, and other violations identified by rule. Read the sanction rule at https://goo.gl/TVVc3A and at https://goo.gl/urWdEq

Utah Department of Health published a new Medicaid Information Bulletin (MIB) effective 01 January 2018. Utah Medicaid providers and other interested persons should review this MIB to identify changes to the Medicaid program to include updates to policy. Medicaid providers are required to know and follow changes to policies. The MIB can be accessed on the Utah Medicaid homepage at: https://medicaid.utah.gov/. A direct link to the MIB is: https://goo.gl/WT1vpe.

Utah Office of Inspector General enforces Medicaid policy defined as the Utah State Plan, Utah Department of Health Administrative Rules, Provider Manuals and Medicaid Information Bulletins. Please contact us to learn more or to report suspected fraud, waste, abuse or mismanagement of the Medicaid program.

Utah Office of Inspector General is created by statute to conduct oversight of the Utah Medicaid program. The office’s oversight focuses on all aspects of the Utah Medicaid program to include traditional Medicaid, referred to sometimes as Fee-For-Service (FFS) Medicaid, and the Managed Care system, known as Managed Care Organizations (MCOs). Managed care is a Medicaid delivery system in which the Utah Department of Health contracts with MCOs to provide Medicaid covered services to enrolled members.

There are three types* of MCOs in the Utah Medicaid system:

1. Physical Health Care: An MCO that provides physical health care services is known as an Accountable Care Organization (ACO).
2. Behavioral Health Care: An MCO that provides behavioral health services is known as a Prepaid Mental Health Plan (PMHP).
3. Dental Services: An MCO that provides dental services is called a Dental Plan.

To learn more about MCOs and how the Utah OIG conducts oversight of the managed care system, please contact us at: UtahOIG@utah.gov or mpi@utah.gov.

* These MCO’s type were obtained from Medicaid’s Section I General Information Manual. Other federal and or state governments might further define what constitutes an MCO. For purposes of this news article we utilized the general definition of an MCO.

Successful medical care requires effective healthcare communication. Having good medical care will ensure Utah taxpayer dollars and resources are efficiently expended in the Utah Medicaid program. The Utah Office of Inspector General’s Pillars for Success are designed to promote strong healthcare communication between the provider and the patient, and help reduce unnecessary waste in the program. Visit the Training Material section to view the Pillars of Success.

The LEIE has been updated on 07 November 2017 with October 2017 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

Utah has been approved by CMS to expand Medicaid to cover additional adults that previously were not eligible for Medicaid. Utah is one of the first in the nation to be approved to expand Medicaid to provide additional access and coverage to treatment for substance use and mental health disorders. This is a significant improvement in access to Utah Medicaid in three ways:

1. Income eligibility levels have been expanded to cover more low income adults. This expansion took effective July 1, 2017.
2. Providing full Medicaid coverage for the chronically homeless, and those in need of substance abuse and mental health treatment.
3. An increase in the number of treatment beds that will be available for mental health and substance use disorder treatment. The number of beds that are available will be expanded to allow for greater access for treatment.

This expansion to Utah Medicaid will take effect immediately and will help further protect vulnerable populations in Utah. Utah Office of Inspector General (UOIG) will continue to monitor the Utah Medicaid program to include this expanded Medicaid coverage to ensure taxpayer dollars are always properly used. Please follow UOIG, the Utah Department of Health or contact Utah Medicaid to learn more.

One of the most effective ways to identify fraud in the health care system is to receive tips from persons with actual knowledge of suspected fraudulent activity. Tips can be the most effective method in finding fraud than any other form of oversight.

If you suspect Medicaid fraud is occurring in Utah, please help stop it by reporting the activity to the Utah Office of Inspector General. We will investigate those tips. By reporting suspected Medicaid fraud, you can help protect Utah taxpayers, the Medicaid program and the honest providers and recipients who are part of the program.

Utah Medicaid began moving policy out of Provider Manuals and into the Utah Administrative Code within Title R414 in July 2017. This is a significant change in the way Utah Medicaid will manage, update, and publish policies. All providers must be aware of this change in policy management. By moving policy to the Admin Rules, providers will have an opportunity to review and comment on policy changes. Provider Manuals will continue to be streamlined with several manuals already consolidated and archived. When reviewing Utah Medicaid policy, providers must review the Utah Administrative Code (Title R414) and the Provider Manuals together.

Title R414 can be accessed at: https://rules.utah.gov/publicat/code/r414/r414.htm

Provider Manuals can be accessed at:
https://medicaid.utah.gov/publications

The public, providers, and other interested groups may follow proposed rule changes and comment on those changes through the Utah State Bulletin containing Official Notices of Utah State Government. The Utah State Bulletin and public notice information is located at:

Utah State Bulletin

Utah Office of Inspector General (UOIG) is pleased to participate in the annual Statewide Provider Training. For 2017, the Statewide Provider Training will be presented via webinars in the coming months. Rather than on-site visits throughout the state, Medicaid trainers are working on a web-based training and outreach program. This new forum will provide current information with frequent updates, and should reach a larger, more diverse group of providers and participants. The Policy and Training Coordinator will present a section for the UOIG.

Utah Medicaid Providers will be notified when more information becomes available on our training page at: https://medicaid.utah.gov/medicaid-provider-training

Please watch for a future MIB that will include additional information about Statewide Provider Training.