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NE Medicaid Comprehensive Program Integrity Review Dec 2010

NE Medicaid Comprehensive Program Integrity Review Dec 2010

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Published by Shelli Dawdy
Department of Health and Human Services Centers for Medicare & Medicaid Services, Medicaid Integrity Program, Nebraska Comprehensive Program Integrity Review Final Report December 2010
Department of Health and Human Services Centers for Medicare & Medicaid Services, Medicaid Integrity Program, Nebraska Comprehensive Program Integrity Review Final Report December 2010

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Published by: Shelli Dawdy on Nov 27, 2011
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Department of Health and Human ServicesCenters for Medicare & Medicaid ServicesMedicaid Integrity ProgramNebraska Comprehensive Program Integrity ReviewFinal ReportDecember 2010
Reviewers:Jeff Coady, Review Team LeaderTonya FullenMark RogersMichael Tripp
 
Nebraska Comprehensive PI Review Final ReportDecember 2010
i
T
ABLE OF
C
ONTENTS
 
Introduction ..................................................................................................................................... 1The Review ..................................................................................................................................... 1Objectives of the Review ............................................................................................................ 1Overview of Nebraska’s Medicaid Program ............................................................................... 1Program Integrity Office ............................................................................................................. 1Methodology of the Review........................................................................................................ 2Scope and Limitations of the Review ......................................................................................... 2Results of the Review ..................................................................................................................... 3Effective Practices ...................................................................................................................... 3Regulatory Compliance Issues .................................................................................................... 4Vulnerabilities ............................................................................................................................. 6Conclusion .................................................................................................................................... 10
 
Nebraska Comprehensive PI Review Final ReportDecember 2010Page 1
I
NTRODUCTION
 
The Centers for Medicare & Medicaid Services’ (CMS) Medicaid Integrity Group (MIG)conducted a comprehensive program integrity review of the Nebraska Medicaid Program. TheMIG review team conducted the onsite portion of the review at the offices of the NebraskaDepartment of Health and Human Services (DHHS). The review team also visited the office of the Medicaid Fraud Control Unit (MFCU).This review focused on the activities of the Division of Medicaid and Long Term Care withinDHHS. The Division is primarily responsible for Medicaid fee-for-service (FFS), waiverprograms, managed care, payments, and provider enrollment. The program integrity operationsare located within the Acute Care Programs of the Division of Medicaid and Long Term Care.This report describes six effective practices, four regulatory compliance issues, and eightvulnerabilities in the State’s program integrity operations.
T
HE
R
EVIEW
 
Objectives of the Review
1.
 
Determine compliance with Federal program integrity laws and regulations;2.
 
Identify program vulnerabilities and effective practices;3.
 
Help Nebraska improve its overall program integrity efforts; and4.
 
Consider opportunities for future technical assistance.
Overview of Nebraska’s Medicaid Program
The DHHS administers the Nebraska Medicaid program. As of June 2009, the program served211,010 recipients. Nebraska's FFS program had 175,239 enrolled recipients, or 83 percent of Nebraska’s Medicaid population.At the time of the review, DHHS had 22,234 participating FFS providers. Approximately 2,938providers are participating in Nebraska’s managed care organization (MCO). Medicaidexpenditures in Nebraska for the State fiscal year (SFY) ending June 30, 2008, totaled$1,496,764,748. The Federal medical assistance percentage for Nebraska for Federal fiscal year2009 was 65.74 percent.
 Program Integrity Office
The Program Integrity (PI) office is the organizational component dedicated to fraud and abuseactivities. At the time of the review, the PI office had approximately five full-time equivalentemployees (FTEs) and two staff vacancies. Two of the five FTEs have been reassigned to work on the development and implementation of a new Medicaid Management Information System(MMIS). During SFY 2006 through SFY 2009, the PI office conducted an annual average of 29preliminary investigations and 115 full investigations. The table below presents the total numberof preliminary and full investigations, State administrative actions, and amount of overpaymentsidentified and collected for the last four SFYs as a result of program integrity activities.

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