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

Utah Medicaid recently published the July 2017 Medicaid Information Bulletin (MIB). This MIB contains important information about various changes to the Utah Medicaid policies and program. The July 2017 MIB consists of 32 Articles. You can read the latest Medicaid newsletter at:

https://medicaid.utah.gov/Documents/manuals/pdfs/Medicaid%20Information%20Bulletins/Traditional%20Medicaid%20Program/2017/July2017-MIB.pdf

All Medicaid providers should read these MIBs as they are published. They are a valuable resource to ensure a good understanding of the Medicaid program and to stay up-to-date with policy changes.

The HHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) has been updated with June 2017 exclusions and reinstatements. This database was updated and published by HHS OIG on 05 July 2017. Utah Medicaid providers should review the updated database at https://oig.hhs.gov/exclusions/index.asp.

For more information about the updated LEIE or questions about the Utah Medicaid policy regarding excluded individuals or entities, please contact the Policy and Training Coordinator at (801) 538-6018 or by email at: santhony@utah.gov.

On this July 4th, Americans throughout the world will celebrate 241 years of freedom and independence. We will come together as one nation to commemorate the commitment to equality, freedom and the belief in Life, Liberty and the Pursuit of Happiness.

As we celebrate the freedoms we hold so dearly, let us remember the sacrifices that so many have made throughout our American history and continue to make to this day. Thousands of service members are currently deployed throughout the world so that we may celebrate our Independence Day. Let us also remember the families of those deployed service members that are standing the watch here at home so they may focus on the mission of protecting us from air, land and sea. With great humility and admiration, the Office of Inspector General thanks all service members, veterans and families for making this sacrifice for our nation. You have acted with great “fidelity and courage, as knowing that now the peace and safety” of this country has relied and for which we are indebted. Thank you for the sacrifice you have made so we may continue to commemorate our independence.

Happy Independence Day to all Americans.

Follow the Utah Office of Inspector General (UOIG) on its updated Twitter page under the user name @UtahOIG. You can connect with us on Twitter using this link: https://twitter.com/utahoig

We will be sharing timely and important information about our office to include training opportunities, oversight activity, news, changes to Medicaid policies and other useful information that will be of interest to the Utah Medicaid provider community, our partners, and the taxpayers of Utah. We strive to be transparent and Twitter provides an additional resource to help accomplish that goal.

Reach out to us on Twitter to learn more about UOIG.

Utah Office of Inspector General (UOIG) has developed tools and methods to efficiently conduct oversight of the Utah Medicaid program. One of those tools is known as a Self Audit. They are an important oversight tool that help to achieve the UOIG mission of identifying root problems that contribute to improper payments.

The Self Audit program was developed to help build partnerships with the provider community that better protect resources. It allows a provider to see the claims review process through the eyes of the UOIG. If a suspected issue is identified early in the oversight process, it may be a good candidate for the Self Audit program. Rather than completing a full investigation, a Self Audit letter is sent out to the provider asking them to conduct a self assessment of the claim. If the provider identifies an error in the claim, the provider can then self-disclose the error and institute corrective actions to prevent future improper payments. This allows for a provider driven solution.

HHS Office of Inspector General and other state programs are utilizing Self Audits as a way to identify a great number of payment errors. UOIG has continued to innovate by identifying these tools and incorporating them into the oversight toolkit.

For more information about Self Audits, contact the UOIG PIO at UtahOIG@utah.gov.

Two Utah Office of Inspector General (UOIG) employees conducted an onsite visit with a Medicaid provider in Weber County. They met with representatives from the provider’s office to discuss internal billing policies and procedures. During the visit guidance and onsite training was provided. They were able to identify for the provider an area for possible improvement in tracking and monitoring payments received for Medicaid patients.

Having onsite visits with Medicaid providers is more than just finding errors. It is an opportunity to see if UOIG can help providers participate more successfully in the program. The office works hard to let the providers know that onsite visits are designed to help them not only be in compliance with Medicaid policies, but to find new or better ways to participate. This approach to oversight benefits the program through improved provider participation and better safeguarding of taxpayer dollars and resources.

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

The Utah Office of Inspector General of Medicaid Services (UOIG) has created a new Facebook page with the user name @UtahOIG. This new Facebook page will allow UOIG the ability to timely share important information about the office and the Utah Medicaid program. As an oversight entity, we strive to be transparent and accountable to the program, our partners, and the taxpayers of Utah. We will now have the opportunity to quickly share more information to help in the success of the Medicaid program. Please visit our Facebook page and provide us with comments and feedback about what you would like to see in the future. We look forward to publishing training material, updates on Medicaid and UOIG policies, and reports on our fraud, waste and abuse investigations and audits.

For more information about the UOIG and for press inquiries, please contact the UOIG Public Information Officer, Mr. Steven Anthony, at 385-831-5397, or by email at santhony@utah.gov.

The Utah Office of Inspector General of Medicaid Services (UOIG), as part of its oversight mission, conducts routine and random onsite visits of Utah Medicaid providers to ensure program compliance and to build partnerships among the provider community. These onsite visits may occur as the result of a providers initial applications to participate in the Medicaid program, during the providers re-validation/re-enrollment process, as part of random monitoring, or as part of UOIG’s annual planning focusing on specific provider communities. Onsite visits may also be requested as part of other oversight activities.

Onsite visits are an important part of the UOIG mission in protecting taxpayer assets and resources. Some of the activity that takes place during these onsite visits may include discussions about office processes and procedures, reviewing of documents and materials, inspection of physical spaces, and the interviewing of management and employees. Any findings identified during the onsite visit will be discussed with the provider to include areas that may help resolve suspect deficiencies.

The UOIG will make every effort to coordinate a convenient time that is most suitable for the providers. The office shall also attempt to minimize interference with patient care and normal operations. Representatives from the UOIG may include Investigators from the Special Investigations Unit (SIU) and/or the Program Integrity Unit (PI), and the Policy and Training Coordinator to help provide onsite training and guidance on policy compliance. The UOIG shall notify providers in writing seven (7) calendar days before the inspection.

One method that may help a provider maintain compliance is Provider Training. UOIG recommends that all Medicaid providers participate in the annual Provider Training series presented and hosted by Utah Medicaid. For questions about Utah Medicaid training opportunities, please contact the Medicaid training representatives at: providertrainingsupport@utah.gov.

Additionally, UOIG is willing to host provider training tailored to specific issues or concerns including, but not limited to the UOIG statute, the office’s mission, Medicaid policies, and providers’ responsibilities and rights under the UOIG Administrative Rules. If you are a Utah Medicaid provider and would like to receive specific provider training, please contact the UOIG’s Training Coordinator at santhony@utah.gov.

For more information about Onsite Inspections from the UOIG, please contact our office at (801) 538-6087.

The Utah Office of Inspector General of Medicaid Services (UOIG) conducts oversight of the Utah Medicaid program pursuant to Utah Code Title 63A, Chapter 13. The mission of UOIG is to provide oversight and monitoring of the Medicaid program to identify and recover improper payments and to make recommendations to the Utah Department of Health on ways to improve program operations and management. The UOIG conducts investigations and reviews of Medicaid claims to identify possible improper payments. Improper payments are categorized as errors, waste, abuse, or fraud. Utah Code 63A-13-102 provides the following important definitions:

Abuse: An action or practice that is inconsistent with sound fiscal, business, or medical practices; and results, or may result, in unnecessary Medicaid related costs; or reckless or negligent upcoding.

Fraud: Intentional or knowing: (a) deception, misrepresentation, or upcoding in relation to Medicaid funds, costs, a claim, reimbursement, or services; or (b) a violation of a provision of Sections 26-20-3 through 26-20-7.

Waste: Overutilization of resources or inappropriate payment.

Upcoding: Assigning an inaccurate billing code for a service that is payable or reimbursable by Medicaid funds, if the correct billing code for the service, taking into account reasonable opinions derived from official published coding definitions, would result in a lower Medicaid payment or reimbursement.

The Centers for Medicare and Medicaid Services (CMS) provides additional guidance to further understand the scale of improper Medicaid payments:

– Errors are simple mistakes made on a claim. Errors can be combined into waste, but have been broken out by CMS as the most simple and unintentional act that results in an overpayment.

– Waste can be inefficiencies within the submission or processing of claims. There is no intentional act to deceive or misrepresent facts.

– Abuse is the bending of the rules to achieve a higher than allowed payment. This may be such things as providing unnecessary services or those that do not meet standards of care. This may
also be a recipient that causes unnecessary services to be provided.

– Fraud is an intentional act or deception. It is a misrepresentation of the facts. This can include concealment of information.

It is important to know that the vast majority of all improper payments are unintentional errors. Errors can happen because a provider or one of their staff simply do not fully understand Medicaid policies. Training can help resolve those misunderstandings and help providers better participate in the Medicaid program.

To report suspected provider or recipient fraud, waste or abuse, or to request training from the UOIG, please contact us at (801) 538-6087.