Utah Medicaid has published a new Medicaid Information Bulletin (MIB) for October 2017. This MIB contains new and important information about the Utah Medicaid program. Please review this MIB to learn more about changes in the program to include important policy updates. Access the MIB here:

https://medicaid.utah.gov/Documents/manuals/pdfs/Medicaid%20Information%20Bulletins/Traditional%20Medicaid%20Program/2017/October2017-MIB.pdf

Utah Medicaid providers have a duty to be aware of changes in the Medicaid program and to follow all current policies. MIBs are a useful tool to stay informed about those changes,

The Federal Anti-Kickback statute prohibits knowingly and willfully soliciting, receiving, offering, or paying anything of value to induce referrals of items or services payable by a federal health care program. Kickbacks are harmful to Medicaid as they can distort medical decision-making, result in over-utilization of services, increase costs to the Utah Medicaid program, and create unfair competition by directly or indirectly forcing out competitors not willing to pay kickbacks. Report suspected violations to the Utah Office of Inspector General.

Collusion among providers occurs when competing providers (competing groups) agree on fees charged & capitation rates accepted to benefit the entire group. Providers could come together to agree on fees to charge or behavior to take that will be of benefit to the entire group. This results in all providers having a better bottom line at the cost of the Utah Medicaid program and taxpayers of Utah. Colluding to benefit the competing providers is a serious violation and unethical behavior. Never fall for collusion in any form. Report suspected collusion to the Utah Office of Inspector General for investigation.

If you are a Utah Medicaid provider or know a Medicaid provider that would like the Utah Office of Inspector General (UOIG) to present a short training at their office, please contact the UOIG Policy and Training Coordinator at: santhony@utah.gov

UOIG can provide a short presentation to a provider’s office during lunch or other convenient time. We are also excited to participate in seminars and conferences focused on related issues. If you are interested, please reach out to arrange a good time. We want to visit you and provide a good presentation about who we are and what the UOIG does for the taxpayers of Utah.”

Utah law requires that a health care professional, a provider, or a state or local government official or employee who becomes aware of fraud, waste, or abuse to report the fraud, waste, or abuse to the Utah Utah Office of Inspector General (UOIG) or Medicaid Fraud Control Unit (MFCU).

A person who reports fraud, waste or abuse to UOIG may request that the person’s name not be released in connection with the investigation. The person’s identity may not be released to any person or entity other than the UOIG, MFCU or law enforcement, unless a court orders that the person’s identity be released.

See Utah Code 63A-13-501 for more information: https://le.utah.gov/xcode/code.html

Many Medicaid recipients are required to enroll with a Managed Care Organization (MCO). An MCO that covers physical health care is called an Accountable Care Organization (ACO); one that covers behavioral health is a Prepaid Mental Health Plan (PMHP), and one that covers dental services is called a dental plan (only for those eligible for full dental coverage). Medicaid members enrolled in MCOs are entitled to the same Medicaid benefits as fee-for-service members. However, MCOs may offer more benefits and may have different prior authorization requirements than the Medicaid scope of benefits. A Medicaid member enrolled in an MCO must receive services through that plan with some exceptions called “carve-out services.”

Medicaid contracts with four ACOs to provide healthcare: HealthChoice of Utah, Healthy U, Molina Healthcare and SelectHealth Community Care.

Learn more about MCOs and ACOs by reviewing the Utah Medicaid Provider Manual, Section I: General Information:

https://medicaid.utah.gov/publications

Provided below is a list of the most common or frequent types of provider fraud:

Billing for Unnecessary Services or Items: Intentionally billing for medical services or items that are not necessary.
Billing for Services or Items Not Provided: Intentionally billing for services or items never provided.
Unbundling: Billing for multiple codes for a group of procedures covered in a global code
Upcoding: Billing a higher cost code than than the service that was actually provided
Card Sharing: Knowingly treating and claiming reimbursement for someone other than the eligible patient.
Collusion: Collaborating with patients to file false claims for reimbursement
Drug Diversion: Writing unnecessary prescriptions, or altering prescriptions, to obtain drugs for personal use or to sell them
Kickbacks: Offering or receiving payments for patient referrals for medical services or items”

CMS provides certain bounds around the definition of “credible allegation of fraud” at 42 C.F.R. § 455.2:

Generally, a “credible allegation of fraud” may be an allegation that has been verified by a State and that has indicia of reliability that comes from any source. A credible allegation of fraud, for example, could be a complaint made by an employee of a physician alleging that the physician is engaged in fraudulent billing practices, i.e., the physician repeatedly bills for services at a higher level than is actually justified by the services rendered to beneficiaries.

Upon the Utah Office of Inspector General (UOIG) review of the physician’s billings, the UOIG investigator may determine that the allegation has indicia of reliability and is, in fact, credible. Indicia of reliability means that there are signs, indications or circumstances that point to the existence of a given fact. If there are signs, indications or circumstances that seem to point to the existence of fraud, there is a credible allegation of fraud. The Medicaid fraud allegation tends to indicate it is probable.

When UOIG identifies a credible allegation of fraud or “potential criminal conduct, relating to Medicaid funds or the state Medicaid program” we refer the case to the Medicaid Fraud Control Unit (MFCU) or to law enforcement. Learn more by reading the CFR, CMS guidelines and the Utah OIG statute:

https://le.utah.gov/xcode/Title63A/Chapter13/63A-13.html?v=C63A-13_1800010118000101

Utah Medicaid providers are prohibited from billing patients. Medicaid providers must accept the payment from Medicaid as payment in full. Providers may not bill Medicaid patients for services that are covered under Medicaid or by a Managed Care Organization (MCO). There are strict exceptions to this policy. Prohibition on billing Medicaid patients policy is located in the Section I: General Information Provider Manual located online at: https://medicaid.utah.gov/utah-medicaid-official-publications.

If you or someone you know has been billed by a provider for a Medicaid covered service, please report that suspected violation of Medicaid policy to the Utah Office of Inspector General.

Utah Medicaid will be making substantial changes to the provider manuals. Medicaid will start moving policy from the provider manuals to the appropriate Utah Administrative Rule within R414, Health, Health Care Financing, Coverage and Reimbursement Policy. Providers will notice this move taking place over the next several quarters. Moving Medicaid policy to the Administrative Rules will allow providers the opportunity to review and comment on rule updates. Providers are encouraged to become familiar with the Administrative Rule, because Medicaid coverage policy will be relocated to the appropriate rule based on service coverage.

The manuals will also be streamlined. For example, ancillary services such as laboratory services and women’s services information will be in the Utah Medicaid Physician Services Provider Manual effective July 1, 2017. As part of the manual revision process, information regarding specific code coverage will be moved from the provider manuals to the Utah Medicaid Coverage and Reimbursement Lookup Tool. The provider manuals will continue to be a reference for criteria and reporting instructions. Providers are encouraged to become familiar with the updated rules and manuals noting changes in the structure, formatting, and content of the manuals. Providers are still required to follow coverage policy, criteria, and prior authorization (PA) requirements.

View the updated provider manuals here: https://medicaid.utah.gov/utah-medicaid-official-publications