Current through Register Vol. 24-18, September 15, 2024
The medicaid agency verifies entities' compliance with
applicable laws, rules, regulations, and agreements through program integrity
activities.
(1)
Methods.
Program integrity activity methods include, but are not limited to:
(a) Data mining to identify possible fraud,
waste, and abuse (FWA) for further examination;
(b) Audits and reviews to determine
compliance with federal, state, and agency rules and regulations, or to
identify FWA;
(c) Investigations of
suspected fraud and abuse;
(d)
Algorithms to identify payment, program, and system irregularities leading to
improper payments;
(e) On-site
reviews and inspections of an entity's premises to ensure compliance with
federal, state, and agency rules and regulations;
(f) Referral of enforcement actions against
entities that have committed fraud or abuse to law enforcement agencies, or
licensing agencies, or both;
(g)
Technical assistance and education to prevent and identify potential
FWA;
(h) Outreach to and education
for entities and client communities, including how to report suspected fraud,
explaining federal, state, and agency rules and requirements, conducting entity
self-audits and implementing compliance programs; and
(i) Initiating and reviewing entity
self-audits under WAC
182-502A-0501.
(2)
Location. Program integrity
activities occur at the agency, an entity's premises, or at both
locations.
(3)
Timing.
The agency may begin program integrity activities concerning any current or
former agency-contracted entity or that entity's agent at any time up to six
years after the date of service.
(4)
Notice.
(a) The agency provides thirty-calendar-days'
notice to entities before an on-site visit, except in those instances
identified in (c) of this subsection.
(b) Hospitals are entitled to notice as
described in
RCW
70.41.045(4).
(c) The agency is not required to give notice
of an on-site visit if evidence exists of danger to public health and safety or
fraudulent activities.
(5)
Scope. The agency determines
the scope of a program integrity activity.
(6)
Selecting information to
evaluate.
(a) The agency may evaluate
any records or other information relevant to validating that the entity
received only those funds to which it is legally entitled.
(b) The agency may select information to
evaluate by:
(i) Conducting a risk assessment
of claim or encounter data;
(ii)
Applying algorithms;
(iii) Data
mining;
(iv) Claim-by-claim
review;
(v) Encounter-by-encounter
review;
(vi) Stratified random
sampling;
(vii) Nonstratified
random sampling; or
(viii) Applying
any other method, or combination of methods, designed to identify relevant
information.
(7)
Collecting records and other
information to evaluate.
(a) After
the agency serves notice, an entity must submit a copy of all records and other
information requested to the agency by the date stated in the
request.
(b) The entity must submit
records electronically or by facsimile and must follow the instructions for
records submission included in the agency's notice, unless the agency gives the
entity permission to submit a hard copy of the records.
(c) If sent electronically, records must be:
(i) Copied to secured media (e.g., CD or DVD)
and sent to the address stated in the notice; or
(ii) Uploaded to the agency's secure file
transfer protocol (SFTP) site.
(d) If an entity submits hard copy records
without prior approval, the agency destroys the records and requires the entity
to resubmit them in an electronic format.
(e) If an entity fails to timely comply with
the request, the agency may:
(i) Deny the
entity's claim under a prepay review process;
(ii) Issue a preliminary finding;
or
(iii) Issue a final
notice
(f) Once a program
integrity activity begins, the entity must retain all original records and
supportive materials until the program integrity activity is completed and all
issues resolved, even if the retention period for those records and materials
extends beyond the period otherwise required by law.
(g) Unless instructed to do so by the agency,
the entity must not adjust or rebill a claim or encounter that is within the
scope of a program integrity activity until that activity ends and any
resulting appeals are exhausted.
(8)
Cooperation with on-site visits,
audits, and investigations. For an on-site visit, audit, or
investigation, the entity must allow the agency access to its premises and
provide any records or other information requested while on-site.
(9)
Evaluating information.
(a) The agency may evaluate relevant
information by applying any method or combination of methods reasonably
calculated to determine whether an entity has complied with an applicable law,
regulation, or agreement.
(b) A
health care provider's bill for services, appointment books, accounting
records, or other similar documents alone do not qualify as appropriate
documentation of services rendered.
(c) The agency provides the entity a
description of the method or combination of methods used by the agency to
select information to evaluate.
(10)
Nonbilled services.
Nonbilled services include any item, drug, code, or payment group that a
provider does not submit on the provider's claim to the agency or contractor.
When calculating improper payments, the agency does not include nonbilled
services in its calculations.
(11)
Paid-at-zero services. The agency considers paid-at-zero services
or supplies only when conducting program integrity activities involving payment
groups or encounters.
(12)
Conducting on-site audits. The agency may conduct on-site audits
at any entity location.
(a) During an on-site
audit, the agency may create a copy of an entity's records that are potentially
relevant to the audit.
(b) Failure
to grant the agency access to the entity's records or premises constitutes
failure to comply with a program integrity activity.
(13)
Conducting interviews. The
agency may interview any person it reasonably believes has relevant information
regarding a program integrity activity. Interviews may consist of one or more
sessions.
(14)
Costs.
The agency does not reimburse the costs an entity incurs complying with program
integrity activities.
(15)
Conducting on-site visits. The agency may conduct on-site
inspections of any entity location to determine whether the entity is complying
with all applicable laws, rules, regulations, and agreements.
