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.

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.

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

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 [email protected].”

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.

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: [email protected] or [email protected].

* 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.