The Latest Threat to CMHCs – Medicaid Integrity Contractor Audits and Investigations

May 11, 2010 by  
Filed under Featured, Medicare Audits

(May 11, 2010):  Over the years, our Firm has represented a significant number of Community Mental Health Clinics (CMHCs) around the country.    While the patient, services offered and payor mix varies from client to client, almost all our clients provide services of some sort which are reimbursable by Medicaid.  As CMHCs and other health care providers are now finding, the level of scrutiny now being placed on Medicaid billings has significantly increased within the last year.

 The purpose of this series of articles is to provide an overview of the Medicaid Integrity Contractor (MIC) program.  Over the next week, we will be providing an overview of this latest enforcement effort by Federal and State authorities.

 I.  Background:  The Deficit Reduction Act of 2005 was signed into law in February 2006.  Among tis provisions, this legislation created the Medicaid Integrity Program (MIP) in Section 1936 of the Social Security Act (Act).   Section 1936 of the Act required that the Centers for Medicare and Medicaid Services (CMS) set up contracts with private, outside contractors, Medicaid Integrity Contractors (MICs), for the purpose of performing four key program integrity functions:

 Review provider actions.

  • Audit Medicaid claims submitted by providers.
  • Identify overpayments.
  • Provide education on program integrity issues.

 Section 1936 of the Act also required that CMS: 

  • Provide support and assistance to States in their efforts to combat Medicaid fraud.
  • Periodically publish a Comprehensive Medicaid Integrity Plan (CMIP).

 Importantly, the MIP represents the first major, coordinated effort by the Federal government to address Medicaid fraud and abuse.  CMS received an initial $5 million in Fiscal Year 2006 and $75 million in Fiscal Year 2009 (and thereafter) to fund these enforcement activities.  Notably, these enforcement efforts were meant to supplement, not supplant, existing efforts by both Federal and State to combat Medicaid fraud. 

 Operationally, the MIP is centrally managed by the Medicaid Integrity Group (MIG).  The MIG reports directly to the “Director of the Center for Medicaid and State Operations.”  The MIG includes:

 Office of the Group Director (serves as primary point of contact in CMS for Medicaid fraud and abuse issues).

Division of Medicaid Integrity Contracting (responsible for the procurement, oversight and evaluation of Medicaid contractors who are conducting audits and identifying overpayments).

Division of Field Operations (works directly with the provider audit contractors).

Division of Fraud Research and Detection (provides research, statistical and data support for both the MIP and the states.  Identifies current and emerging fraud trends).

In 2008, the MIG began work on a “MIG Data Engine,” the first national database of Medicaid claims.  This has enabled the Federal government to conduct complex data mining reviews and has facilitated the identification of health care providers who are “outliers.”   Working with State Medicaid Fraud Control Units (MFCUs), HHS-OIG and DOJ have ramped up the intensity of Medicaid audits and investigations to never before seen levels.  

Over the next week, we will examine the types of MIC contractors established under the MIP.  We will also discuss steps you should take NOW to prepare for an audit.  Finally, we will discuss a number of points you should how you should consider if your clinic or practice is subjected to a Medicaid audit.

Should you have any questions regarding these changes, don’t hesitate to contact us.  For a complementary consultation, you may call Robert W. Liles or one of our other attorneys at 1 (800) 475-1906.