Compliance Investigations

Background

MN Rules part 9505.2160 establishes a program of surveillance, integrity, review, and control. It also authorizes a post-payment review process to ensure compliance with State and Federal requirements by monitoring the use of health services by members and the delivery of health services by providers. Within PrimeWest Health, the Compliance department is responsible for investigating suspected errors and fraud, waste, and abuse. PrimeWest Health may seek monetary recovery or refer the case to an outside authority (local, State or Federal) to impose administrative sanctions and/or to seek civil or criminal remedies. 

Investigative Process

Compliance staff has the authority to conduct routine audits and monitoring of providers to assess compliance with program requirements.

1. Compliance staff are authorized to use information from sources including the following:
   1. Government agencies;
   2. Professional review organizations;
   3. Consultants under contract;
   4. Members and their responsible relatives;
   5. Providers and persons employed by or under contract with providers;
   6. Professional associations of providers and their peers;
   7. Site visits; and
   8. Quality Initiative (QI) studies completed by provider organizations. This includes full cooperation with HEDIS chart abstractions and allowing abstractors full access to medical records and the right to copy/scan supporting documentation from the chart.
2. Compliance investigations may include the following:
   1. Examination of health service and financial records;
   2. Examination of prescriptions written for PrimeWest Health members;
   3. Interviews of contacts described previously;
   4. Verification of the professional credentials of a provider, the provider’s employees, and entities under contract with the provider;
   5. Consultation with PrimeWest Health peer review mechanisms;
   6. Site visits; and 
   7. Determination of whether the health care provided was medically necessary.
3. Following completion of the investigation, PrimeWest Health determines the following:
   1. If the provider is in compliance with the requirements of a program;
   2. If insufficient evidence exists that potential fraud, waste, or abuse has occurred; or
   3. If evidence of potential fraud, waste, or abuse supports administrative, civil, or criminal action.

Monetary Recovery and Administrative Sanctions

1. After completing the investigation, PrimeWest Health takes one or more of the following actions:
   1. Closes the investigation when no further action is warranted;
   2. Imposes administrative sanctions;
   3. Seeks monetary recovery;
   4. Refers the investigation to the appropriate regulatory agency or authority;
   5. Refers the investigation to the attorney general or, if appropriate, to a county attorney for possible civil or criminal legal action; or
   6. Issues a warning that states the practices are potentially in violation of program laws or regulations.
2. PrimeWest Health seeks monetary recovery from a provider if payment for a member’s health service under PrimeWest Health was the result of fraud, waste, abuse, or error on the part of the provider, PrimeWest Health, or local agency. PrimeWest Health is authorized to calculate the amount of monetary recovery based on estimation from systematic random samples of claims submitted and paid. PrimeWest Health recovers money by the following means:
   1. Permitting voluntary repayment of money, either in lump sum payment or installment payments;
      1. If PrimeWest Health permits use of installment payments, PrimeWest Health assesses interest on the funds, unless the overpayment occurred because of PrimeWest Health error. The rate is established by the Department of Revenue.
   2. Recapturing or offsetting from claims on future remittance advices from PrimeWest Health payments;
   3. Withholding payments to a provider under 42 CFR 447.31; or 
   4. Using any legal collection process.
3. If a provider willfully submits a claim for reimbursement for medical care or services the provider knows or reasonably should have known is a false representation and which results in payments for which the provider is ineligible, PrimeWest Health may seek recovery of investigative costs.
4. Administrative sanctions may be imposed for any of the following:
   1. Potential fraud, waste, or abuse in connection with health care services billed to PrimeWest Health; and
   2. Refusal to grant PrimeWest Health access to records.
5. For a provider, the sanctions that may be imposed include the following:
   1. Suspending or terminating the provider’s participation;
   2. Suspending or terminating the participation of any person or corporation with whom the provider has any ownership or control interest;
   3. Requiring attendance at education sessions provided by PrimeWest Health or DHS;
   4. Requiring authorization of services; and
   5. Restricting or suspending the provider’s participation in PrimeWest Health.
6. For a provider, the sanctions which may be imposed are those described previously, as well as:
   1. Requiring a Provider Participation Agreement of limited duration;
   2. Requiring a Provider Participation Agreement that stipulates specific conditions of participation; and
   3. Review of the provider’s claims before payment.
7. PrimeWest Health has the authority to simultaneously seek monetary recovery and to administer sanctions.
8. PrimeWest Health notifies providers in writing of any intent to recover money or impose sanctions.
9. A provider may meet with PrimeWest Health informally to discuss the matter in dispute.
10. A provider has the right to Appeal PrimeWest Health’s proposed action. An Appeal is considered timely if written notice of Appeal is filed with PrimeWest Health within 10 days of the date that the notice of proposed action was mailed. The Appeal request must specify the following:
    1. Each disputed item;
    2. The reason for the dispute;
    3. An estimate of the dollar amount involved, if any, for each disputed item;
    4. The computation or other disposition that the appealing party believes is correct;
    5. The authority in Statute or Rule upon which the appealing party relies for each disputed item;
    6. The name and address of the person or firm with whom contracts may be made regarding the Appeal; and
    7. Other pertinent information as may be required by PrimeWest Health.
11. The Appeal is a contested case proceeding under the provisions of the Minnesota Administrative Procedure Act.
12. Under certain conditions, PrimeWest Health has the authority to withhold payments to a provider prior to notice or to a hearing.
13. No claims may be submitted personally by a provider who has been suspended or terminated from PrimeWest Health, nor may claims be submitted by any clinic, group, corporation, or association on behalf of a provider who has been suspended or terminated from PrimeWest Health. Claims for health care provided prior to the suspension or termination may be submitted, but will be subject to review.
14. The provider who is restricted from participation may not submit a claim for payment under PrimeWest Health for services or charges specified in the notice of action, either through a claim as an individual or through a claim submitted by a clinic, group, corporation, or professional association, except in the case of claims for payment for health services otherwise eligible for payment and provided before the restriction. No payments may be made to a provider, either directly or indirectly, for restricted services or charges specified in the notice of action.
15. A provider who is convicted of a crime related to the provision, management, or administration of PrimeWest Health related health services will be suspended from participation effective on the date of conviction. PrimeWest Health will notify the provider of the date and duration of the suspension.

Fraud or Abuse of Medicare/Medical Assistance (Medicaid) Programs

PrimeWest Health will suspend or terminate any provider who has been suspended or is currently under suspension or termination from participation in the Medicare/Medicaid programs because of fraud, waste, or abuse.

Crimes Related to Minnesota Health Care Programs (MHCP)

Convicted: A judgment of conviction has been entered by a Federal, State, or local court, regardless of whether an Appeal from the judgment is pending, and includes a plea of guilty or nolo contendere.

1. A provider convicted of an MHCP-related crime is automatically suspended from participation in PrimeWest Health. The effective date of the suspension is the date of the conviction. DHS notifies the provider of the date and duration of the suspension. PrimeWest Health enforces the action of DHS.
2. Suspension and termination sanctions are applicable to providers who share ownership or control interest with a provider convicted of a crime related to MHCP. The determination of ownership or control interest is made using the definitions in 42 CFR 455.101 and 42 CFR 455.102. A provider suspended under this provision may seek reinstatement as a provider when the convicted provider ceases ownership or control interest in the other provider.

A provider is notified in writing of PrimeWest Health’s intent to suspend the provider from PrimeWest Health participation, the reasons for the suspension, and the effective date and duration of the suspension.

Reporting Suspected Fraud, Waste, or Abuse

To report suspected fraud, waste, or abuse by a provider, call the PrimeWest Health Compliance Hotline at 1-866-763-2952 (toll free).

Updated_02/27/2020