@ PCG |Health Public Focus. Proven Results.” New Mexico Human Services Department Behavioral Health Provider Audits Final Report CONFIDENTIAL June 21, 2013 atc costing Gi he an At Act Cepeh ny EgSine of New Mexia Homan Seviees Deparment EU Dehra ve Ae EXECUTIVE SUMMARY {In February 2013, the New Mexico Human Services Department (HSD) contracted with Public Consulting Group Ine, (PCG) to aut fieen (15) mental health and substance abuse providers statewide. In 2012, these providers constituted approximately 87% ofall Core Service Agency (CSA) spending for Medicaid and non-Medicaid behavioral health servies!. PCG's audit ‘consisted of three main components 1) Clinical Case File Ault ~ a review of case fle documentation, including safing ‘qualifications and eredenils; 2) Billing Systems Audit ~ a review ofthe billing system itself, as wel as the protocols ‘and processes employed by the provide; and, 3) Enerprse Audit ~ a review of the organization and its key stakeholders, third party contracts, and other stakeholder relationships. ing. an approsch developed and refined through auditing behavioral health providers e nationally and ttlored to New Mexico's payment rules and regulations, PCG's multi-faceted suit arived atthe following Findings: 1) Clinical Findings: Wentfed more than $36.0 million in overpayments to these 15 providers over 8 thee-year period from 2009-2012. This amounts to nearly 15% ofall payments made to these providers. A 2003 Congressional General Accounting Office (GAO) report stated that Medicaid fraud, waste, and abuse is expected to be 3% 1 9% oF all payments. PCG recommends the collection of these overpayments 2) ITiiling System Findings: No material findings, though PCG did idetfy weaknesses in provider billing processes, including lack of audit tails when it eomes to changes made in systems. Generally, PCG recommends that providers tighten billing process ‘controls 3) Enterprise Findings: \dentfed potential confiets of interests of some individuals and some of the audited provides. PCG recommends thatthe State of New Mexico further ‘review instances of potential conflicts of interest «Contos gen ot pve pont a een tt ye ew Mes kee ere rg ee a fet, malate rataae co ameedsceeage a Ce acter etn te ey eo =x PagelI mall ect pum cys Behav Hei Prove Aude Sa ‘Execute Suny Summary of Clinical Audit CG's clinical ease fle review utilized two different methodologies foreach provider: 1) Random sampling of provider claims ~ Audit of 150 randomly sampled claims that were submitted by the providers. The sampling methodology allows for a statistically valid extrapolation of the findings. 2) Consumer ease file review ~ A review ofa full year's worth of case file document for selected consumers, These findings are not extrapolated, but ean be used to identify deficiencies that cannot be identified when viewing a single claim, PGs clinical case fle review revealed moderate to significant levels of non-compliance with state payment rules and regulations. Generally, the provides reviewed inthis audit lack many of the appropriate safeguards against overiling and would benefit from targeted technical assistance. Additionally, PCG's findings reveal deficiencies in accuracy of clinical documentation, which signifies potential quality of care concerns that shouldbe further reviewed bythe State of New Mexico, PCG utilized an audit too! developed and refined through auditing behaviors! health providers rationally and tailored to New Mexico's payment rules and regulations. For the randomly sampled clsims PCO uilized a statistically significant extrapolation methodology to identify ‘more than $33.8 milion in overpayments to these |5 providers over a three-year period from 2009-2012. With te consumer case file, oF “longitudinal,” reviews PCG identified an ‘addtional S2.1 millon in overpayments to these 15 providers over the same thre year period, for total extimated overpayments of $36.0 milion (nesrly 15% of claims paid during this petiod). Below are non-compliance rates and extrapolated overpayments by provider ToeitRemiais fini ne , vnleria aoeee [ae eee woue | ae ee | ee ane ae wet ae eee ee fe te feat ue ee ae a fea | ae pee fae tae oer ee ee fees [ae | eee ee if ee feel eee eee foe ae eee te ae ee ee ee ee ae reese eee ee ee ee ee tee ee fae pa tee got fae eee [em ae ae eee aS eee Its important to note that only the more egregious errors were used to extrapolate the amounts owed across the universe of claims for these providers. & more sct review ofthe randomly sampled provide claims originally indicated a non-compliance rate of 74%, PCG classified a numberof thes findings as “poor documentation practices” that should be remedied through a combination of tainings, technical assistance, and clinical and management assistance. “These errors included missing signatures, inadequate case note competion, and below standard preparation of plans of care. Had PCG used these erors in the extrapolation, the resulting ‘overpayment amounts would have been much greater. PCG considers the extent ofits findings to bea significant concer forthe Sate of New Mexico. In 2 2003 repor” the Congressional General Accounting Office (GAO) estimated that fraud, waste, and abuse amounted to between 3% and 9% of total Mediesidsrending. Using this GAO ‘study as base, this audit reveals overpayments that are double what can be expected. coca Acovtng Ofc, “ajo ManagenentChaleges nd Popa Risks Deparment of Heath an Human Services" 2003 bap wor gn gov esetsa40237027 pot agemill fil meine tits chav eats Provide Audis FURL Cons Executive Say Summary of TPBillng Systems Aual CG did not identify any specific instances of tampering with the providers’ billing systems. This finding mst be qualified for several reasons. First, PCG was unable to complete 8 comprehensive review of all billing systems as one of the billing systems vendors, Anasazi, prohibited providers from sharing system manuals, as they were considered proprietary (noted in that PCG viewed from Anasazi to one ofthe audited providers). Aditionaly, PCG lading identified areas of weaknesses in provider practices, ‘© Lack of audit tral for the creation of and changes made w claim records in provider billing systems; + Lack of audit irl for any changes made to the 837 reports ling system outputs) prior to finalizing inthe Automated Clearing House portal Summary of Enterprise Ault Lastly, PCG's enterprise audit sought to a) provide the state witha clearer view of how its provider system is organized and b) identity any potential appearances of conflicts of interest for the organization and its key board members and employees. The enterprise audit revealed that some providers may have potential conflicts of interest that should be further reviewed by ‘the State of New Mexico. Examples of the types of potential confit of interest and areas that, CG recommends further research include ‘+ Unusual compensation andor benefits to some key stakeholders; ‘© Key stakeholders’ relationships with releted parties with financial interests in veanset ‘+ Some arrangements with thied parties are unclear as © the level of effor and compensation for some executives and, + Non-dislosure of ll thied party contracts. Scorecard and Risk Tier Results Based on the elnial case file compliance outcomes and findings related to IT controls, PCG developed, in conjunction with HSD, a “seorecard™ for each provider. Below, PCG has eePRL oNSLING 7 ‘organized the providers’ scorecard resus in relation to each other. The scorecard ranges from “Significant Non-Compliance” to “Compliant.” Camplance PCG then used these provider scorecard ratings to categorize providers into “Risk Tier” replete With recommended state ations, a8 flows: Findings that include missing Provide trainings and elnical, documents te. assistance as needed. 7 Significant volume of findings that] Provide trainings and clinical include missing documents assistance as needed. ‘Potentially embedcliical management {improve process. | Significant findings, including Provide —talnings — and lineal signifean quay of care findings. assistance as needed. ‘+ Potentially embedclinical management to improve processes. Potential change in management. "> Mandatory changein management. PaeeVmii Sua often Mesen iM Il wena uae got ovis Based on PCG's scorecard methodology, each ofthe 1S providers was categorized into a Risk ‘Tle, the results of which are shown below. 1 ‘© Provide trainings and clinical assistance as needed. 2 > Provide Wanings and clinical assistance as | M,C,1,D,J,L,HyandN needed. + Potentially embed clinical management to improve processes. 3+ Provide trainings and elinieal assistance as] E,G,A,F,K,O and B needed, ‘+ Potentially embed clinical management to lmprove processes. Potential change in managerent q ‘= Mandatory change in management ‘See NOTE, below NOTE». Please note that Ter 4: Credible Allegation f Fraud isa determination tht can only ‘be made bythe Sate of New Mexico. PCG ualized results from its clinical case file audit and Thing. system audit to develop the scorecard, which translated into providers being ‘categorized in Tiers 1, 2, and 3. The State of New Mexico may determine that information ‘provided inthe case fle, IT/biling system, and enterprise audits constiutes a re-categorization ‘of one or more providers into a higher riskier, including Ter 4. Rackgeon {In February 2013, the New Mexico Human Services Department (HSD) determined the need for 18 comprehensive clinical and billing auit of select providers within its behavioral heath system and engaged Public Consulting Group (PCG) to conduet these audis. Claims data mining bythe state's behavioral health vendor revealed a significant numberof potential biling abnormalities. These potential billing abnormalities included, but were not limited to, the following data and case file “findings” Tae vi‘Soe ofNew Meso Homan Serves Department Belair Heath Provider Aa Exectve Samay i a ~ Cross billing at diferent locations for the same member pote uncertain as o who rendered the service (iF rendered at all); + Insufficient documentation; = Cross billing mulkiple codes and double billing (eg individual and group therapy); Upcoding individual therapy (compared to the average time billed per code inthe peer group) Excessive billing for psychosocial rehab; including requesting authorization for a consumer on medical leave; = Suspicious high volume days per one code; ovebilling for inappropriate codes; psychosocial rehabilitation billed for large units on a given date to one clinician; excessive hours per day billed by practitioner; excessive hours of service billed per patent per code; billing for services duplicative in nature; = eentitying Provider a the rendering clinician; [No medal necessity reviews to determine basis for long-term psychotherapy Forging clinician recorés to incorporate more ime than truly performed; (Out of home placement services outside norm of service; doubtful medical needs ~ Billing outpatient services the same day as bundled services, ally overlapping time: [Not all of the aforementioned potential billing issues can be addressed with a single audit, panicularly when an objective ofthe aut isto identify recoupable overpayments, In order to recoup across a universe of pad claims, a more comprehensive review is required, Nerowly focusing on one particular suspicious trend in «provider's claims history inhibits the ability of the auditor and the state to extrapolate those results aeross the entire claims history, Rather than tempting to address each provider's uniquely identified issues, PCG worked with HSD to develop a comprehensive approach that would serutnie individual providers holistically (as ‘opposed to looking ata few aberrant trends that may or may not run afoul of policy even if substantiated) and the system at large. This approach was characterized by three main goals: 1) Identify potential credible allegations of fraudulent activity. 2) ent egulatry compliance lvls of behavior! heat providers 3) entity areas of weakness that must be strengthened prior to the implementation of Centennial Care. PCG was tasked with conducting onsite audits of selected providers to examine case files supporting specific claims, IT systems and processes, and edherence with compliance protocols, {nd to examine existing relationship, financial or other, among providers and other entities, The ‘onsite audits were conducted in February and March and included interviews with relevantanil vmaticatee — @ rau Cons Behavioral Healy Provider Ate Excetve Summary provider staff, collection of hard copy and electronic file documents related to the sbove mentioned areas, and examination and manual testing of IT systems. The onsite visits were supplemented by desk reviews of collected documentation at a locaton separate from the provider site, PCG's approach is deserted in more dealin the body ofthe fll report. Key Findings While each provider is unique wih respect to clinical findings, PCG identified certain cormmon themes across many ofthe 5 provides reviewed, which ae described below. For each provider, 2 section is included in the appendix that shows the detailed clinical findings specific to that provider, PCG's findings include: ‘+ More than $37.3 million in overpayments for these 15 providers over a three end a half year period July 2009-January 2013). This extrapolated overpayment amounts 10 15% of {ota payments from state sources to these providers during this time period ‘+ Non-compliance with many New Mexico state rules and regulations. Pervasive issues that PG identified across providers include: e Randomly Sampled Clains 1© Community Support Workers lacked evidence of completion of the requted ‘raining per the service definition, ‘© Assessments (psychosocalpsychatic evaluations) were not up to date (within last 12 months) to determine if the consumer continued to meet the need of the rendered service. Incomplete critical information suchas Five Axis diagnosis ‘+ Substance abuse history was absent for most consumers with a dual iagnosis of mental health and substance abuse ‘©. Treatment plans were not up-to-date and individualized per consumer. Updated treatment plans are necessary to determine any changes to goalsfobjectves in addition o progress or lack of progress by the consumer. Without continuously ‘updated treatment plans, it is impossible to determine if the treatment imervetion till meet the behavioral health needs ofthe consumer. * GoalsObjectives were not measurable and did not document achievable target dates based onthe consumer's needs. Service specific clinical interventions used to reach goalslobjectves were absent @e fim i Sin of Now Meso Hanan Soe Depernent unui gongunve avira eh roi: Ae Execute Sma * Discharge plans and estimated length of teament were not documented ‘© Consumer Documentation ' Consents for medications rendered were abser. Documentation frequently did not describe the clinical interventions, rogres o lack of progress toward zoals,andnex steps in treatment ‘Interventions inthe progress notes didnot alvays lnk to the consumer tweatment plan or support the program definition of the billed service. ‘Progress notes did not contain a start and sop time of @ duration that would enable determination as to whether the bile time was accurate, * Billed unite did not match the units documented onthe progress notes. Intensive Outpatient Program progress notes di not contin the treatment ‘modalities used a required in the service defriton * Documented evidence of the required treatment team was absent for most team services. Longitudinal File Review Findings SefetyRisk Assessments were not completed or updaed for consumers who were assessed t0 have curent or past suicidal ideations (S.), homicidal ideatons (Hl), ‘selTharm or domestic violence issues ‘Treatment plans were not up-to-date and individualized per consumer. * Plans conained the same gols/objectves for more than 12 months, Potential overutilization of services without documented justification of the service relate to extensive length of stay. Consumer Documentation Documentation frequently did not describe the clinical interventions, progress or lack of progress toward goals and 2ext steps in treatment. 1 Progress notes did not contain a start and stop time or @ duration that ‘would enable a determination as to whether the billed time was accurate, ‘Billed unis did not match the units documented on the progress notes. ‘+ Weaknesses identified in providers" billing processes. PCG identified weaknesses in internal claims processes. PCG was unable to complete a comprehensive review of al billing systems as one particular billing software vendor was unwilling to allow providers to share with PCG important documentation and information abou the system.a nial — runt CONLIN Execute Senna + Potential conflicts of interest in selected providers. PCG identified areas of potential conflicts of interest among some proviers, individuals, and related parties. Examples of the types of potential conflicts of interest and areas that PCG recommends further research include: © Unus 1 compensation and/or benefits to some key stakeholders; (© Key stakeholders’ relationships related partes with financial interests in (© Some arrangements with third parties ae unclear as tothe level of effort and compensation for some executives; and, ‘© Nondiglosure of ll third party contacts. Key Recommendations ‘+ Standardize clinical documentation across providers. In order to ensure tat all ritcal behavioral health consumer information is gathered and properly documented, PCG recommends that standardized forms be uted sero all providers. The standardized forms at a minimum would include assessments, testment plans, and progress notes (daily/wecklylogs), Please refer to Section 4 ofthe report for specific recommendstons. ‘Implement a comprehensive program integrity effort for behavioral heath services. PCG recommends this Pl effort be written into MCO coniacts and be implemented by the state for non-Medicad programs. This means more than just pos-payment auditing ‘Teaditional “pay and chase” models should be supplemented by pre-payment measures and more proactive provider education, oversight and monitoring efforts to proactively prevent erors fom occuring prior to payment. ‘+ Provide technical assistance to providers in the areas of clinical best practices and billing processes and procedures. ‘+ Review and revamp New Mexico's behavioral health provider billing rules and regulations. Specifically, PCG recommends certain “best practices” that should be required information. Please refer to Section 4 ofthe report fr recommendations. ‘+ Enforce payment regulations Payment rules and regulations are developed for severe! reasons, the primary of which is to ensure that consumers receive high-quality care. PeekaS eo fill eee FURIC CONSULTING Belair Heath Prove Audie EQN Exec Sr ‘+ Maximize the utility of the editing capabilites of claims processing systems to prevent overpayments, Where functionality is lacking or inadequate to suficientl vet claims pre-submission to avoid inappropriate billing. providers should engage in cliscussions with their EMR vendors to identify and implement the requisite safeguards, ‘Thorough training of billing tf? on new or previously unused system functionality wil further ensure proper front end billing. ‘+ Complete additional reviews of potential conflicts of interest, Beyond the recommendations mentioned above, PCG was asked to provide editions recommendations forthe New Mexico behavioral health system, based on te firm's national experience working with behavioral health and other community based providers. PCG recommends the following: + Convene stakeholder (sate, vendors, and providers) workgroups to deveop ‘Outcomes Measures. Working ogether, stakeholders can define the particular outcomes that New Mexico chooses to pursue. With speife measures in hand, work cn beginon Oo collecting the selevant information and. data points, which will spawn fruifl ‘converatins abou qui of cre end reimbursement reform, + Enforce Behavioral Health Providers’ important role in Health Care Reform. A primary argument in favor of health care reform i its potential to achieve cost svings by focusing attention on the small percentage ofthe population tht consumes the largest share of health care services. Better management of eare for those individuals can concurrently yield improvements in quality and decreased costs for services. Particularly in the case of publicly funded programs, individuals with chronic illness ofen have a primary or secondary behavioral health diagnosis. Behavioral health providers must be front and center in conversations regarding proactive management of care for this Population. PagetSune 21,2013, Sn oe Mein Human Serves Deparment Betairl Heh Pier Aus nal Report TABLE OF CONTENTS 2. introduction 1 2. Background and Understanding 2.1 Purpose of Procurement 7 2.2 Scope of Work e 13. auaeapproach 13. Preparingand Depoying Aut Teams 13.2 Establishing protocols for each component of the audit 10 3.3 Onsite data collection 10 3.4 Coordination wth State and Manage Care Orgoiation Staff 10 3.5 Produton of Final Aud Report n 4. fave le Reviews 1.1 Case le Review Methodology a 12 Provider Selection a 1.3 aim Selection 15 143.1 Random Samples of 005 15 1432 Longtudinal Reviews 16 ‘44 aud Tool Reviews 36 45 Barapolaton Methodology 8 {48 Key Case Fle Finangs 2 447 Key Recommendations u 5. 1/ting ystems Reviews 30 Appendices ‘Audit Protocole = Provider Audit o Counseling Associates, ne, Aust Pei Consuiag Grp, PagetSections 1-5 2 rape of nacre 2asope owen 2. Ast rach 31 repuing and Oelyng Aud Teams often 24 corton wh Sad Managed Care orsnnantn sat aod of ol ut Report 4. cam rites “Cane eve Methodology @ ‘amon seton ‘3am Secon nua tot nevews ‘Starapoten eodteny ‘rteyReemencatos e nil unc coNgULTING1. IntroductionSte of New Meseo Till ii Lesage ree URC CONSUL ml Repo 1. Introduction In February 2013, the New Mexico Human Services Department (HSD) contracted with Public ‘Consulting Group, Ine. (PCG) to aut fifteen (15) mental health and substance cbuse providers statewide, in 2012, these providers constituted approximately 87% of all Core Service Agency (CSA) spending for Medicaid and non-Medicaid behavioral health services! PCG's aut consisted of three msn components 1) Clinical Case File Audit ~ a review of case file documentation, inc wing staffing ‘qualifications and credentials; 2) I7Billing Systems Audit ~ a review ofthe billing system itself, as well a the protocols and processes employed by the provider; and, 3) Enterprise Audit ~ a review of the organization and its key stakeholders, thied party ‘contracts and other stakeholder relationships Utilizing an approach developed and refined through auditing behavioral health providers rationally and tailored to New Mexico's payment rules and regulations, PCG's multi-faceted audit arrived atthe following findings: 1) Clinical Findings: Wdentiied more than $36.0 million in overpayments to these 15 providers over a three-year period fom 2009-2012. This amounts to neatly 15% of all ‘payments made to these providers. A 2003 Congressional General Accounting Office (GAO) repor stated that Medicaid fraud, waste, and abuse is expected 0 be 3% t0 994 of all payments, PCG recommends the collection ofthese overpayments 2) IUBitling System Findings: No material findings, though PCG did ideniy weaknesses in provider biling processes, including lack of audit tails when it comes to changes made in systems. Generally, PCG recommends that provides tighten billing process controls, 3) Enterprise Findings: \dentified potential conflicts of interests of some individuals and ‘some of the audited providers. PCG recommends thatthe State of New Mexico further ‘review instances of potential conics of interest. "are Servin Agereis, or SA. provider agian that hve btn designated by the New Mexico ‘Behavioral Heath Colibeve to be teense ar inl oneation of ee for cheno al, PCOS ‘at ned 12 of he sae’ 15 CSAR- Estate percentage of CSA ependng lized 2009-2012 fot spending foreach CSA ‘CONFIDENTIAL PagetBehavior Hel rover As PURCCONSUETI. ia Rape a fall semen Summary of Clinical Audit CG's clinical cas ile review ulized two different methodologies for each provider: 1) Random sampling of provider claims ~ Audit of randomly sampled claims that were submited by the provides. The sampling methodology allows for a statistically vali ‘extrapolation ofthe fr 2) Consumer case file review — A review ofa full year's worth of case file notes for selected consumers. Thes findings are not extrapolated, but can be used to identify deficiencies that cannot be identified when viewing single claim. PCGs clinical case file review revealed moderate to significant levels of non-compliance with state payment rules and regulations. Generally, the providers reviewed inthis euit lack many of the appropriate safeguards against overbiling and would benefit from targeted technical assistance. Additionally, PCG's findings reveal deficiencies in accuracy of clinical ‘documentation, which signifies peential quality of eare concerns that should be futher reviewed by the State of New Mexico. CG utilized an auit tol developed and refined through auitng behavioral health providers rationally and tailoed to New Mexico's payment rules and regulations, For the randomly sampled claims PCG utilized a statistically significant extrapolation methodology to identify ‘more than $33.8 milion in overpayments to these I providers over a three-year prio from 2009-2012. With the consumer ease file, of “longitudinal,” reviews PCG identified an ‘ditional $2.1 milion in overpuyments to these 15 providers over the same three yea period, {or total estimated overpaymexts of $36.0 million (nearly 15% of claims paid during this period). Below ae non-compliance rates and extrapolated overpayments by provider: ‘CONFIDENTIAL. Page?@ Ti il Bete as Pv ha Gill ial Rept 73% 86% 200%. O74 133% 778% S7BSs 53% 3E% $5551 21% 0.7%, 03 33%. a1 14018 23% 648% | _sr7e905 113% 20.0%. ‘$45,157 60%. S764 7. 2:36 a0 7.1% L 367% | 3130440 | 340% 35% 757388 | sae | 3 153% | sunmanes [ono | —su757 | 81 zi% | sami | 02% | sssse | Provider O | 359% | $0), 74s e@ jand Total | 23.7% | $33,868.18 | 57.1% | S,112a34 _[ Ss980,607 It is important to note that only the more egregious errort were used to extrapolate the amounts owed across the universe of claims for these providers. A mor strict review of the randomly sampled provider claims originally indicated a non-compliance rate of 74%. PCG classified a number ofthese findings as “poor documentation practices” that shouldbe remedied ‘through a combination of trainings, technical assistance, and clirical and management assistance ‘These errors included missing signatures, inadequate case note completion, and below standard preparation of plans of care, Had PCG used these errors in the extrapolation, the resulting ‘overpayment amounts would have been much greater PCG considers he extent of is findings to bea significant concen forthe State of New Mexico. In e 2003 repor’, the Congressional General Accounting Offee (GAO) estimated that fraud, waste, and abuse amounted to between 3% and 9% of total Medicaid spending. Using this GAO study as a base, this audit reveals overpayments that are double what can be expected. Summary of IF Bling Systems Andie PCG did not identity any specific instances of tampering with the provides’ billing systems. This finding must be qualified for several reasons, Fist, PCG was unble to complete a @ General Accounting Offi, "Major Managemen Chuilegs an Progam Riss: Deprnent of Heth and Homan ‘Seevees” 20%: hpe ga gvlnes0299027 pa ‘CONFIDENTIAL Pagenil iS comprehensive review of all billing systems as one of the billing systems vendors, Anasizi, prohibited providers from sharing system manuals, s they were considered proprietary (noted in fn email that PCG viewed from Anasazi to one ofthe audited providers). Additionally, PCG identified areas of weaknesses in provider practices, including ‘+ Lack of auit tal fr the cretion of and changes made to billing systems; records in provider ‘+ Lack of audit tril for any changes made to the 837 reports (billing system outputs) prior to finalizing inthe Automated Clearing House portal ‘Summary of Enerprse Aualt Lastly, PCG's enterprise audit sought to a) provide the state with a clearer view of how its provider system is organized and b) identify any potential appearances of conflicts of interest for the organization and its key board members snd employees. The enterprise audit revealed tht some providers may have potential conflicts of interest that should be further reviewed by the State of New Mexico. Examples of the types of potetial conflicts of interest and areas that PCG recommends further research include: ‘Unusual compensation andor benefits to some key stakeholders; ‘© Key stakeholders’ relationships with related parties with financial interests in transactions; + Some arrangements with thitd parties are unclear as to the level of effort a ‘compensation for some executives; and, ‘+ Non-dislosure of ll third party contact. ‘Scorecard and Risk Tier Results ‘Based on the clnial case file compliance outcomes and findings related to IT controls, PCG developed, in conjunction with HSD, a “scorecard” for each provider. Below, PCG has ‘organized the providers’ scorecard results in relation to each other. The scorecard ranges from “Significant Non-Compliance” to “Compliant ‘CONFIDENTIAL PaaeeB= of ceo fil — mill a SEC A Crt CO then used these provider scorecard ratings to categorize providers into “Risk Ties,” replete ‘wilh recommended state wetons, as follows: 1 [Findings that include mising ‘Provide trainings and clinical documents, ec. _ sasiatance as needed. Z| Significant volume of findings that | Provide trainings and elinial Include missing documents assistance as needed. ‘Potentially embed clnial management 0 improve processes. 3 | Significant ndings, nclading * Provide wainings and clinical significant quality of care findings. assistance as needed. ‘+ Potentially embed clinical management to improve processes. ‘Potential change in management. | Credible Allegation oF Fraud Mandatory change in management ‘CONFIDENTIAL Peersunas Seve Deprtnest Betavio! Heath Provider Ae usc CONSULTING Fl Repo at piper Till Based on PCG's scorecard methodology, each ofthe IS providers was categorized into a Risk ‘Tier, the results of which are shown below. 1 ‘© Provide trainings and clinical asitance as needed. I] + Provide Wahingy nd ca anise as | WG LDL aa needed + Potetly embod cline! management 19 improve proces. 3] + Provide tninings and cna eetsance ws] EGA K Ome seote 4 Potetily embed cline! management to |” improve process. Potential change. in renageneat T= Mander age ean NOTE Row] [NOTE:- Pease note tha Ter 4: Credibe Allegation of Fraud sa determination that can only ‘be made by the State of New Mexico. PCG utlized results from its clinical case fle audit and Titling system audit 10 develop the scorecard, which translated into providers being ‘categorized in Tiers 1, 2, and 3. The Siate of New Mexico may determine tht information provided in the case file, [Tiling system, and enterprise audits constitutes a re-categrization ‘of one or more providers into a higher risk tier, including Tier 4. ‘CONADENTIAL Taare2. Background and Understanding 24 Purpore of Procurement 22 Scope of Workfil coon ruc CONSTI Pl Repo 2. BACKGROUND AND UNDERSTANDING 24. Purpose of Procurement In February 2013, the New Mexieo Human Services Department (HSD) determined the need for ‘comprehensive clinica an billing aut of select providers within its behaviorl neath system and engaged Public Consulting Group (PCG) to conduct these ais. Claims data mining by the state's behavioral health vendor revealed a significant number of potential billing ebnormlites. ‘These potential billing abnormalities included, but were not limited to, the following findings" = Cross billing at different locations forthe same member potentially overapping time; Lncertinty as to who rendered the service (if rendered at + Insufficient documentation; = Cros billing multiple codes and double biling (eg. ~ Upcoding individual therapy (compared to the average time billed per code in the peer Br0up); + Excessive billing for psychosocial rehab; including requesting authorization for consumer on medical lave; Suspicious high volume days per one code; overbilling for inappropriate codes; psychosocial rehabilitation billed for large units on a given date to ove clinician; ‘excessive hours per day billed by practitioner; excesive hours of service billed per patient pe code; billing for services duplicative in nature: = Wentfying Provider asthe rendering clinician "No medical necessity reviews to determine basis for long-term psychotherapy; Forging clinician records to incorporate more time than truly performed; + Outof home placement services outside norm of service; doubtful medical need; + Billing outpatient services the same day as bundled se Not all of the aforementioned potential billing issues ean be addressed with a single audit, Particularly when an objective ofthe audit is 1 identity recoupable overpayments In order 19 recoup across a universe of paid claims, © more comprehensive review is required, Nerowly focusing on one particular suspicious tend in a providers claims history it the autor andthe state fo extrapolate those results across the entire claims satempting to address each provider's uniquely identified issues, PCG worked with HSD to develep s comprehensive approsch that would scratnize individual provides holsticaly (as ‘opposed to looking at afew aberrant trends that may or may not run afoul of policy, even if substantiated) and the system at large, This approach was characterized by thee main goals: “CONFDENT inmares Pa a ‘CONFDENTIALat sua of Now Meson mill wlan 1) Identity potential credible allegations of fraudulent activi 2) Identify regulatory compliance levels of behavioral health providers and, 5) Identify areas of weakness that must be strengthened prior to the implementation of ‘Centennial Care. PCG was tasked with conducting onsite audits of selected providers to examine case files supporting specifi claims, IT systems end processes, and adherence with compliance protocols, and 10 examine existing relationships among providers (enterprise audi, The results of the enterprise portion of the audits will be presented in «separate report. The onsite audits were condcted in February and March, and included interviews with relevant provider staff coletion of hard copy and electronic fle documents related tothe above mentioned areas, and fexarrination and manual testing of IT systems. The onsite visits were supplemented by desk ‘eviews of collected documentation ata location separate from the provider site, PCG's approach is decribed in more detail inthe next section, 22 Scope of Work Under the signed Agreement between HSD and PCG, PCG was engaged to serve as project rmaniger in coordinating audits and analysis of 15 of New Mexico's Medicaid managed care ‘orgasization (MCO) network of behavioral health providers. The providers were identified by the HSD. PCG's scope of work included three main audit components for each of the 15 providers: 1) Clinical Case File Audits to ensure that providers are adhering to New Mexico payment rules and regulations; 2 IT/Biling Systems Audit to ensure that systems are bring used properly and in accordance with New Mexico payment rules and regulation; and 5) Enterprise Audit to ensure that each of the orgaizstions’ coniractual and business relationships are conducted in accordance with Federal and New Nexo lew, cules, and regulations PC's approach and protocols foreach of these aut components are described in the subsequent sections ofthis report ‘CONFIDENTIAL Pare3. Audit Approach aera eee 3.1 Preparing and Deploying Aust Teame 3.2 Establishing protocols for each component ofthe audit 3.3 Onsite data collection 34 Coordination wth State and Managed Care ‘Organization Staff 35 Production of Final Audit Reportfil vata uRLCCONSING: ina Repe 3. AUDIT APPROACH 34 Preparing and Deploying Audit Teams Under the Agreement between HSD and PCG, PCG was responsible forthe organization of onsite visits and offsite reviews, including preparing audit teams. Each project team was comprised of three tofive individuals including the following specific roles: + Team Lead: The Team Lead was responsible for overseeing the general operation ofthe ‘onsite visits. Speife functions included: ‘© Initieting onsite communication with provider staff ‘©. Facilitating the entrance discussion, including explaining the purpose ofthe visit, expectations for provider assistance and actions to be earied eu/protocos to be followed by the audit tam during onsite time; ‘© Coordinating team activites to ensure that team members were connected with the appropriate provider staff members and were able to collect the required information; (© Conducting interviews with Key provider administrative staf; and (© Facilitating the exit discussion and communicating any addtional, Informationnent steps to provider ‘+ Administrative Support: Administrative support staff, which in some eases included team members with clinical experience, had primary responsibility for data collection and storage and provided as needed support to the other teum members, Specific functions included: ‘© Physically collecting documentation given by the provider, which in some cases included manually extracting documentation from case files: © Scanning and/or uploading al collected files; ‘© Participating in as needed interviews with provider staff and documenting these interviews; (© entitying missing information and working with providers to obtain tht information. ‘CONFIDENTIAL Paes+ Information Technology (7) Lead: The \T Lead had primary responsibility for working with the provider's IT staff to analyze IT systems, thle applications and functionality. Specific functions included (© Collecting documentation regarding IT infrastructure and all software systems curently in us, specifically those used fo capturing other relevant clinical information; and ‘0 As appropriate, manually testing system functionality to determine the link betwen system inputs and outputs and to idemfy any areas of concer. In addition to the above mentioned PCG staf roles, for two weeks of the audit PCG team members were accompanied by State staf acting in administrative suppor roles. Inclusion of Sate staff in audit teams reinforced HSD's role as the authorizing entity for the adits and further ensured coordination of onsite auits between HSD and PCG. 32 Establishing protocols foreach component ofthe audit PCG established auditing standards according to HSD's sated needs, with each component of the audit being assigned its own set of procedures, documentation requests and information callection tools. The specifi components of the clinical and ITblling audits end associated rotcols ar addressed in great detail n sections 4 and Sof this epor. 33° Onsite data collection Upon arriving at each provider ste, PCG conducted an entrance conference at which the purpose ofthe audit was explained and provider staff were given the list of claims (eg, patient name, service rendered, date(s) of service, et.) selected for auditing and asked to pull the appropriate ‘medical records forthe claims in question. PCG also provided a Document Request List that Identified all ofthe documentation (case file, IT/biling and enterprise) expected to be provided aspart ofthe aut ‘The PCG team brought portable scanners to each provider location and any documents provided in hard (paper) copy were scanned and seved ona secure, enerypted laptop. Electronic files that Iles on the laptops were uploaded to a secure, HIPAA-compliant site for safe storage; files were then deleted from the laptops and all USB drives. 34 Coordination with State and Managed Care Organization Staff CeNFIDENTAL PageRE CORRUUTIN. rl Repo a rill 7 ‘Throughout the audit process, PCG worked closely with sta from both HSD and Optum, the ‘managed are organization responsible for the administration of ll State behavioral helth funds, to keep both partes apprised of audit progress and o preemptively identify and discuss concerns related to consumer safety that migh arise in relation to the aus, 35 Production of Final Audit Report Upon competion ofthe date collection, review and analysis processes, PCG was tasked with the development and submission to HSD ofa final audit report capturing all cemponents ofthe audit process and highlighting key findings and recommendations generated by the audits, both atthe ‘comprehensive system wide and provider-pecifi levels. This dacument serves a that repor. For more deals of PCG's audit protocols, please se the Audit Protocols potion ofthis report. ‘CONFDENTIAL. Fase4. Case File Reviews 4.1 Case File Review Methodology 42 Provider Selection 443 Claim Selection 443.1 Random Samples of 005 43.2 Longitudinal Reviews 45 Extrapolation Methodology 45 key Cae File Findings Key RecommendationsTil Tl ‘State of New Mexico il saltnnsosetre ee “aan 4, CASE FILE REVIEWS Clinical and case fle reviews comprised the most significant element of PCG's review. ‘Administrative and clinical staff applied rigorous analysis to all paid claims selected for review. (Our methodology focused on providing assurance that payment of claims is consistent withthe ‘administrative, credentialing, and clinical requirements set forth in the state's payment segulationt: 4.1 Case File Review Methodology ‘At the start of the onsite audits, PCG presented providers with « notification from HSD ‘denifying the clients whose cas files hed been randomly selected for audit and requesting that the provider have available al related service documents for review nat limited to Psycho social assessments ‘© Paychiarc evaluations + Treatment plans/person-centered plans ‘+ Service note/progress notes © Consens ‘© Refers, and “+ Authorizationsfervie orders During onsite visits, the PCG team lead requested thatthe provider walk through the layout of the clnial record withthe team to identify provider specific documents such as assessments, notes, consents, te, the purpose of which was to eid PCG's ability quickly and accurately deni the appropriate documentation within the case files. In action to documentation regarding the services provided, PCG requested from the provider personnel documents related to the qualifications for staff that rendsred services to selected recipients. This documentation included ata minimum the relevant providers: ‘Supervision Notes, ifrequired by service Criminal Background Checks (specific to Respite Care, Resiental, Foster Care) 1+ License to Practice ‘+ Academie/Profesional Degrees (Masters, Bachelors, High School, GED) © Resumes ‘+ Certifications (Board Certification, Certified Peer Specialist) + Trainings “coneNTAL PietTTS ai | ‘State of New Mexico: im | cocaine OT re In addition to saffspecific information, PCG requested agency documentation related to personnel polices and procedures for maintaining staff qualifications. ‘The goal ofthis credentialing review was to address questions including Does tne rendering practioner havea current valid license to pracice? Did her she receive the appropriate tetning to provide the service rendered? What i the status of clinical privileges atthe Institution designated by the service provider asthe primary admitting Facility, if applicable? ‘+ Does 4 valid drug enforcement agency (DEA) or controlled substance registration (CSR) certificate exist, i applicable? [As with all gathered documentation, all files were scanned, logged, and pleaded to the secure website, ‘Once the onsite data collection process had concluded and case files had been examined for completeness and accuracy, the reviewing clinicians were notified that ease files were ready for clinieal review and the documents were downloaded from the secure webste, All cases were reviewed using an audit tool containing broad set of questions specifically geared toward Identifying appropiate billing, excessive billing, ovrutlizaton, duplicate bling, and upeoding, and examining coordination of care and renderer of service. For certain service types, addtional service-speciic questions were applied inorder to ensure a comprehensive program review thet captured the unigue facets ofthat particular service, 42 Provider Selection ‘As stated previously, HSD identified fftcen (15) behavioral health providers mn New Mexico for PCG to audit. Thetable below lists the providers that were audited as part ofthis process. Are Metal Heath Servis Tos S104 Counsng Asin oe 5 95na Fale and Youth ie 3 pseri0 Togas ne 30s Pare in Walle LLC 5 — 200.9 S_aso070 357287 597s Paty ne Preyer Medel Sense Eater Sens EI Mirador ‘CONFIDENTIAL Paca ae ‘State of New Mexico mi fl Ill mn Se Bots belied bone eee IN eit Se Opn Yun ams SSS sho Ooigma [sir — 6 Si Conn a sa — ‘estroge Taga —1$ aT as al Contain Sai ant ‘oa Deacon iso [tes tr iat — "yam “The majority of the selected providers have several facilities loceied within the state, representing approximately 108 facilities, shown onthe map below by county and orgenization, CONFIDENTIAL Pagefil enim ruc EONSING ial Rept 43 Claim Selection Due tothe large volume of claims to analyze, audit sampling was applied. Audit sampling isthe application ofan audit procedure to less than 100% ofthe population to evaluate auit evidence within a class of transactions (claims) for the purpose of forming « conclusion concerning the population, The simple size creates a risk thatthe conclusions may be different from the ‘onelusions that would have been reached based on the whole population. ‘The most common types of sampling used are systematic sampling and random sampling. Random sampling ensures equal chances of selection, whereas systematic sampling involves Using @ fixed interval between selections (eg. every 10th sample; first interval has @ random stan. PCG spied random sampling to analyze the data. Sampling documentation ineludes the source ofthe population, te sampling method used, sampling parameters, items selected, dels of audit tests performed, and conclusions reached. CG executed a two-pronged approach fo the selection of claims for review ~ random samples for date of services and longitudinal eviews, both of which are described below. 42.1 Random Samples for Date of Service ‘The frst prong was afl, statistically valid random sample of al claims foreach provider. PCG randomly selected 150 claims ffom each provider fora full case file review. It was critical in selecting samples for case file review to ensure randomness 50 thatthe review was fut tothe provider and was demonstrable as such to imperial parties during the due process phase, as ‘many such reviews might be subject to appeal. During PCG’s visit to Optum Heath (Optu), ‘Optum staff provided PCG with all pad claims data for providers subject to this review. PCG extracted the claims data and uploaded it nto @ SQL database for analytical review, validation, and ultimately sample selection. PCG employed RAT-STATs, an Office of Inspector General (©1G) approved statistical sampling package to drive the sample selection for this engagement POG has employed RAT-STATS in multiple engagements and is well-versed inal faces ofthe program. The program produces a "seed" number to demonstrat the randomness ofthe sample should a provider appeal on the grounds that claims were selectively targeted and do not represent the entirety of thee claim universe. The statistically valid random sample enables PCO to extrapolate any findings over the entre universe of claims fora provider in determining ‘overpayment amounts. ‘CONFIDENTIAL PagesI Siate of New Mexico e fil i eal ee oie 43.2. Longitudinal Reviews The second prong of our approach was fo conduct targeted chim selection proces. Through is ‘data analytes process and through tips from whistleblowers, Optum had identified potentially ‘outlying claims foreach ofthe providers under audit. Several ofthe procedure codes identified as potentially being ovebilled are codes billed in 15 minute increments and are billed over an ‘extended period of time Its often conceming to payers of health cae claims when the units of service do not dectease overtime within these codes fora given individual and is sometimes & “red flag” that a provider is billing for that service for that individual in an “autopilot” mode or that the consumer isnot making the desired progress. For these types of tends, it isnot possible to diagnose a biling issue by reviewing ony a single date of service. In some eases, one may ‘conclude that these tends represent potentially abusive billing and in others thatthe duration and intensity of services ae appropriate for that consumer. One cannot, however, conclude these things by looking at single pont in ime. ‘Through a targeted claim selection process, POG identified highly utilized codes (as determined by their percentage of total pad claims tothe provides) by indviduel providers. Following the @ selection ofthe codes, PCG isolated the consumers for witow the greatest number of units for these procedure codes had been billed over a 12-month period (Calendar Year 2012), removed those clsims ffom the universe of claims subject to random sampling, requested documentation associated with claims submited on behalf of those consumers and aid the entre length of stay. This allowed our review team to ensure through examination of treatment plans, service authorizations, progress notes, and other documentation that che services were, in fet taking place and tht the high level of service was necessary for that consumer given the diagnosis and goals ofthe individual, For each provider, PCG identified the 2-3 such procedure codes with the highest spend and selected the 5 consumers with the most units billed. I should be noted thatthe targeted claim selection process is not statistically valid and sannot be extrapolate to claims ‘other than those claims that are reviewed. It is intended to provde an extensive, thorough review for a small number of consumers so that HSD can determine if « more widespread review is ‘warranted. 44 AuditTool Reviews ‘The audit ool questions were developed based on both the New Mexico Administrative Code tnd the New Mexico Interagency Behavioral Health Service Requirements and Utilization Guidelines. A broad set of questions was employed, coupled with me specific questions tullored foreach service sampled. ‘CONFIDENTIAL Page 6iil wleaiet unc CoN a eget Tl Sine of New Mexia ‘The brod set of questions inthe tool specifically related to excessive billing, overutlization, Auplicat billing, coordination of care, upcoding, and renderer of sevice Some ofthe key ‘questions asked about each elsim included: 1. Do the units pid match the units of service documented forte sampled procedure ‘code? Was the amount of rendered units appropiate forthe recipient? (excessive billing 2. Was the service delivered medically necessary and appropri (oveutlization)? 3. Does the documentation support, or relate to, the rendered service? 4 Does the procedure code match the documented duration of time spent serving the 5, Were multiple units/encountrs| recipient inthe same day? 6. Were the billed services rendered by qualified staff? led forthe same procedure code forthe sme In addition to auditing for excessive billing, overtlzation, duplicate bling, coordination of 2, upcoding, and inappropriate service delivery as outlined above, a specific set of audit (questions developed and utilized foreach sampled service type covered he categories below: + Service Definition + Target Population + Program Requiements + Provider Requirements + Staff Requirements + Documentation Requirements + Service Exclusions ‘+ -Admission/Continuing/Discharge Criteria For each claim, the reviewing liicin provided a response to each clinical question, Possible responses were: + NofNot Met + Not Applicable + YeuYes Met Comments ae equired fr No(Not Met and followed by the New Mexico Adminitrative Code (NMAC), New Mexico Service Definitions and Level of Cae citation verbiage ‘CONFIDENTIAL Peee finn oo runic const Final Repo 45 Extrapolation Methodology PCG performed both «targeted review and a statistically valid random sample review ofall billed behavioral health services procedure codes on behalf of HSD. First, PCG targeted one _year's worth of billed high risk procedure codes from the five highest elaimed-for recipients at ‘ach ofthe providers and peeformed an administrative and clinical eview ofthe validity ofeach Lill claim. The resulting averpayment validated by PCG was calculated based on the dollar value of only those paid claims from the universe of claims reviewed found to be out of ‘compliance with New Mexico's clinieal andor biling eiteria, The results ofthese reviews was ‘not extrapolated beyond the specific claims PCG reviewed, Second, PCG selected a statistically valid random sample of 150 of the remaining clams from the universe of claims paid to esch provider pald between July 1, 2009 and January 31,2013. ‘The resulting overpayment validated by PCG was representative ofthe universe of elaims from ‘which the sample was selected and was extrpolated over the entire universe of claims (xcluding thse claims selecteé for targeted review) in compliance with auditing procedure ‘regulations found in New Mexico Administrative Code Til 8, Chapter 351, Part 2 @ rarer Review ‘The first goal ofthe review process was to identify a targeted selection of claims based on the procedure codes billed. Those coces include: ‘90791 | Psychlavie Diagnostic Evaluation ‘0801 | Peehiavie Diagnostic Evaluation 90802 | eracive Pech Evaluation 90804 | Ovtpatient—20-30 mines 90806 | Outpatient—45-50 mines 90807 | Outpatient psychotherapy wit EM 45-50 mines 90808 | Outpatent—75-50 minutes 90812 | Iiercive Psychotherapy —a5 30 mina ‘90514 | ersetive Therapy —75-80 minutes 30834 | Ourpatent 45 mina 30837 | Ourpatent—60 miner 30846 | Family Therapy 90847 | Family Therapy @ 90849 | Ouaenr Psychotherapy Servion: ‘cONNDENTAL Patefinn ines A ae PUSAN a ai loaner a fost Ti pee vn fi Pw vr — rei is — ieee — “ar ame stone ——— tains "a — [oasis Tu pig Taree ies Seren a outta oa fsa —— or [eta Ta PCG selected between one and five of these procedure codes at each reviewed provider tnd then sslected the five recipients who accounted for the highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100 percent ofthe clsims associated with each selected procedure code and recipient which were paid ‘uring calendar year 2012. In total, PCG's targeted review included 23,764 claims from 210 of the highest billed-for recipients across 15 providers. ‘Random Sample Review Because behavioral health services typically feture high volumes of low-cost claims, PCG selected statistically valid simple random selection of claims and extrapolated our findings scrss the claims universe using standards consistent with those used by the U.S. DHHS Office ‘CONFIDENTIAL Pafi eS e a ae en fifi alin ona mucosa tate of Aulit Services, endorsed by the Centers for Medicare and Medicaid Services (CMS), erd supported by New Mexico Administrative Code. Sampling i a statistical technique designed lo produce a subset of elements drawn ftom a population, which represents the characteristics of ‘that population. The goal of sampling is to determine the qualities of the population without examising all the elements in that population. All samples.consistedof 150 claims per provider and were selected from the entice universe of paid claims for each provider between July 1, 2009 and January 31, 2013. CMS OIG seta ‘minimam standard of 100 claims for use in extapoation, thus the 150 claim sample size is more ‘han afequate to meet the statistically valid threshold produced by RAT-STATS as well «5 ‘compliance with the OIG standard. This approach allowed fora comprehensive view of bing practices that was representative of the provider's clinical and bilingpoliey compliance during this period of time. Samples were randomly selected using the OlG-developed statistical sampling software RAT-STATS, “The steps to conduct this sampling process and overpayment extrapolation include: ® Step | Define the universe / population ‘The universe was defined as the total set of claims paid between July 1, 2009 and January 31, 2013 from each reviewed provider minus any claims which were selected for the Targeted Review. PCG pulled these claim extracts (ie. universes) and retained them in a spreadshet ‘numbered I 10 (n), where (a isthe total number of elaims. Step 2~Determine sample size While he U.S. DDHS Office of Ault Services commonly uses minimum sample sizes of 100 claims, PCG chose to review 150 claims to improve the precision of ou samples. ‘Step 3 Select the Sample Random seletion of claims is necessary inorder to produce a valid sample. In PCG's random sample, claims are selected from a population in such a way that the simple is unbiased and closely reflects the characteristics of the universe at large. AS a result, the sample allows ax sccurats portayal of what is occuring aeross the univers. PCG ued the O1G-developed RAT-STATS random number generator to idemtily the ‘numbers to be selected from the universe spreadsheet. This RAT-STATS random oumber ‘generation software was extensively tested by the National Bureau of Standards using 12 CONFIDENTIAL eemin oo uur conse nl Report certification programs to ensure randomness and passed all 13 of these tess, Following tis ‘andom number generation, RAT-STATS generates a seed number which serves as an auditable reference point should the numbers need to be regenerated at later date ‘The specifi step used for selection of samples in this process include: |. Using a random number generator (ex: ovivrandom.on), generate a ndom number to be ued asthe seed number associated withthe sample. 2. Open the RAT-STATS statistical software and navigate to Random Numbers>Single ‘Stage Random Numbers. 3, Select *yes" to "Do you want to enter a seed number and input the seed number from above. Input the desired number of claims forthe sample inthe Sequential Order Box. Enter the range of values inthe Low Number (1) and High Number (n) bo ‘Output to an excel file and sve as a backup, . Using the random numbers spreadsheet, identify the claims from the universe to be included in the audit by selecting thse line numbers that were pulled. Step 4 ~ Aust the Sample Each randomly selected claim was reviewed for compliance with New Mexico's clinical and billing poticies and to ensue the legitimacy of the state's payment, as described in Section 4.4 ‘The dollar values of any claims validated as non-compliant were classified as overpayments. Step$ —Estrapoate the results ‘The results of PCG's audits were extrapolated using RAT-STATS. PCG fist created two spreadsheets; one to record the detiled audit results (ie. sample item wit the diference amount) and one o include the sampling detail (ie. numberof items inthe universe and number sampled). Once ths information has been entered and saved, PCG inputs this information into RAT-STATS. RAT-STATS identifies the overpayment amount using the Lower Bound of the 90% confidence interval, meaning that, in lay terms, there is a 95% chance that the actual overpayment amount (if all claims were to be audited) would be higher than the estimated overpayment amount. “The specific steps used for extrapolating the esults of our findings areas follows: ‘CONFIDENTIAL PagelSuto New Mexia im || i aman Services Deparment e@ ‘Behav Hels Pov Aas ee 2 Fira Rept 1. Query the states claims dats o pull the total claims universe for each provider and copy to Spreadsheet #1 2, Create a Spreadsheet #2 with five columns: Stratum (column A), Paid Amount (8), [Examined Amount (C), Sample Size (D), and Universe Size (E), Input the correct information into the appropriate column for each provider 4. Insert two columns: the spreadsheet-columns- and C. ‘Save the spreadsheet using the naming convention [ProviderName}ExtrapolatonFile [¥YYYMMDD] (Open RAT-STATS and go to Varieble Apprisals > Unrestricted Enter the total Universe Value from Spreadsheet Click Specify Input File, choose Excel and choose the Spreadsheet #2 (On the nex screen, choose Examined and Audited Values, and Output to Text the text file withthe same naming convention asthe excel file, le. Save @ 10, Ente the sample sizeof the case 11. Click OK twice, and then click Additional Summary Info twice, 12. The recoupment amount is the 90% Lower Limit ‘Typically, extremely low ates of noncompliance result in poor precision, Therefore, if both the claims eror rate and the paid error rate ae les than 5%, extrapolation is not used and the ‘overpayment amount is simply the sum of the sample overpayment emus, 46 Key Case le Findings PCG's Case File Audit did not uncover what it would consider to be credible allegations of fraud, nr any significant concerns related to consumer safety. However, PCG's review revealed «provider system in need of technical assistance, especially considering the selmi shif thatthe state's behavioral health system wil undergo withthe transition to Centennial Care in January 2014 Uiilzing a statistically significant extrapolation methodology, PCG identified more than $33. tillion in overpayments to these 15 providers over a thre year period from 2009-2012 (13.5% ‘of total payment). CONPDENTAL rea at of New Meio fll SS a ee SUSTASTE 327708 a5 056 8958 SHS ‘S706 335786267 BGR SE Sa sTE “SISTA i Sino 69 S06 Se 26 S6T266 ‘sista ss7614 SUIT ASS a $109 aT cs Sisoaa BsnaG By S273 Siig 2 Si sr7a3302 ar 39202711 Sa099598 Es 3565509 Tau — —s250678327 BIT Dae SSESBAIS— TR While each provider is unique with respect to clinical findings, PCG identified a few common themes across many ofthe 15 providers reviewed. Each provider as a specific section in the report that provides the deiled clinical findings. Non-compliance with many New Mexico state rules and regulations was common. Provider-spcifc findings are located within each provider's audit section. Generally, PCG found the following issues across providers: (© Community Support Workers lacked evidence of completion of the required training per the service definition. ©. Safety/Risk Assessments were not completed or updated for consumers who were assessed to have curent or past suicidal ideatons (SI), homicidal ideatons (0), sf harm or domestic violence issues ‘©. Assessment (psychosocal/psychiatric evaluations) were not up to date (within last 12 momths) to determine ifthe consumer continued to meet the need of the rendered sevice. ' Incomplete iia information such as Five Axis diagnosis. 1 Substance abuse history was absent for most consumers with a dual- diagnosis of mental health and substance abuse.e ii Tl Sine of New Meco Hunan Service Dearne Setar Heath Povicer Ava eal Rept ‘©. Treatment plans were not up-to-date and individualized per consumer. Updated treatment plans are necessary to determine any changes to goalvobjectives in addition to progress or lack of progress by the consumer. Without continuously Updated tweatment plans, it possible so determine if the treatment interventions still met the behavioral health neds ofthe consumer. Plans contained the same goalslobjectves for more than 12 months Potential overutlization of services without documented justification of the service related to extensive length of say. Goals!Objectives were not measurable and did not document achievable target dates based onthe consumer's neecs. Service-specificlinical interventions used to reach goalslobjestives were absent, Discharge plans and estimated length of treatment were not documented forall consumers, Documented discharge plans were rarely individualized © Consumer Documentation @ . Consents for medications rendered were absent Documentation frequently did not describe the clinical interventions, progress or lack of progress toward goals, and next steps in retment Interventions inthe progress nots didnot always lnk to the consumer's tceatment plan or support the program defrition ofthe billed service. Progress notes did not contain a stat and stop time or a duration that would enable a determination a5 to whether the billed time was accurate. Billed units did nt match the units docurented onthe progress notes. Intensive Outpatient Program progress note didnot contain the trestment ‘modalities used as required in the service definition, Documented evidence ofthe required treatment team was absent for most 4.7 Key Recommendations Below, PCG has compiled of recommended best practices that New Mexico should include in its payment rules and regulations. Many of these are already included in payment rules and regulations but appear not to always be enfored. PCO recommends thatthe policies be reviewed and strengthened (ie, clarified so there Is common understanding among HSD and providers) and enforced by all payers (ether the state or a contracted MCO). The recommended best practices are divided into ease fle components: assessments, treatment plans, and progress nots, ‘CONRDENTIAL PesceSte of New Merico Homa See Beta Hea rover Adie el Report “The date of intial contact snd admission date; ‘+ The consumer’s name and contact information (nelading ‘ddress/phone and emergency contat information); ‘+ The consumer's age, selPidenified-yender-& ethnicity, and smart status, “+ Information about significant where in the consumers life including guardian/conservstor or ether legal representatives; “© Theconsumer’s schoo! andar empleyment information; end, ‘© Other identifying information, as applicable such as Medicaid denifiation Number. Communication Commmunicalion needs are assessed fer whether materials noe service provision are required in a different format (eg. other languages, interpreter services, et). I required, indicate whether it waswill be provided, and document any linkage ofthe consumer to culture-specific andlor linguistic services in the communi Providers are required to offer linguistic services and document the offer was made; if the consumer prefers & family member as imerpreter, document that preference. Service-elated correspondence with the consumer must be in their prefered Janguagelformet. Relevant physical health conditions ‘Relevant physical healihcovdiions reported by the consumer oF FY other report must be prominently identified and updated, as appropriate. Presenting problen/eferal reason & relevant conditions ‘Presening problemirefrral_recson relevent condilions affecting the consumer's physical health, mental health stetus and psychosocial conditions (eg. living situation, cally activities, social support, et.) Includes problem definitions by the censumer, significant others and referral soutes, as relevant. ‘petal status stations ‘Special status situations that presenta risk te the consumer or fothers must be prominently documented and updated, 18 appropriate. These might include imminent risk of harm, suiciél ‘or homicidal ideations, sel-injuricus behaviors, or possible slopement. If rsk situation is identified, the Treatment Plan must include how i is being managed, ‘CONFIDENTIALe iil fi ae Retr paella perio oes ere Spano alper =< Terrase ‘Substance we, past & Tash selewrent “Ateohol, caffeine, nieotine, ici substances, and prescribed @ ‘overthe-counter drugs (as applicable). “Menta health sory “Mental health history, ieloding previous Geatment datee and providers; therapeutic interventions and responses; sources of Goals and objectives should be specific and measureable, and oallobjectives inked tothe Assessments clinical analysis and diagnosis (ie. | rust be related to mental health barriers t reaching ‘consumer's goals). Provide estimated time frames (arget dates) | for attainment ofboth short and long term goalslobjecives. Tnterventions Tnterventions and their focus must be consistent with the ‘behavioral health goaslobjectves and must meet the medical necessity requirement thatthe proposed intervention(s) will have a positive impact on the identified impairments. Providers should indicate: «# Service Interventions, hich are the planned behavioral health services (¢ Individual Psychotherapy); ‘Interventions. should be appropriate to the consumer's Aiagnosis, age and intellectual needs; ‘+ Documented linkage of interventions tothe rendered service Time spent providing sevice. The progessnete must ecntsin either a sar and sop time or total duration ofthe rendered service. acumentaion | » Reason forthe contact. = Assessment of consumer's current clinical presentation = Specific behavioral healvelinial interventions by provider, er ype ‘of service and scope of practic. = Consumer's response o interventions. = Strengths and limitations in achieving treatment plan peals/objectves © Plans, next steps, andor clinical decisins. Tf Title er no progress toward goals/cbjectives is being made, desrike why. Include date of next planned contact and/or next clinician action. Indicate referrals made. > Address any Tesues of Hk: IF rdks are present, Fisk assessment Gr “no harm” agreement must be completed. = Signatue/Credentals/Date ofthe person wh rendered the sevice. CONFIDENTIAL FordSEER Ue oo Bee TTT 5. IT/Billing Systems Reviewse fim i nena UB CONTIN Fina Repo 5. ITPBilling Systems Reviews CG Information Technology staff accompanied PCG audit teams for onsite audits for 1S New Mexico Betavioral Health Providers in February and March 2013, ‘As mentioned before, review of information technology (IT) systems included examination of provider IT systems, thee inputs, outputs, and claims processing. The purpose of the IT aust as to verily if evidence existed in the IT systems and procedures to support the preliminery audi findings. The IT systems that were reviewed include each providers + ly ys 1 por auboranton Syn + CinealSynom (a Beevonlc Hath Reso) {Raye there now npc) ® binge ror types he a a ec cairns wich ce cand an tr ln tow ‘+ Human error in dats entry or processing steps ‘Unintentional software processing error ‘+ Deliberate action taken to alter the records either by a human or computer 80 they do mt match treatment given General Controls Control structure ofthe provider affects its IT operations. During the onsite audits, audit teams collected documentation in order to evaluate and document: ‘+ Organizational Controls decision flows within he organization ‘+ Data Center and Network Operations Controls — how isthe proper enty of data ensured ‘and what isthe procedure for error corestion? ‘+ Hardware & Software Acquistion and Maintenance Controls + Access Security Controls ~how isthe computer equipment, software, nd data potectec? ‘What procedures are in place inthe event ofan unauthorized use? ‘CONFIDENTIAL new‘Smteof New Mexico anil erred Func conSULIN, al Repo “+ Application Sytem Acquistion, Development, and Maintenance Controls how isthe reliability of information processing ensured? “+ Managerial conros- ae the IT ases protected from unauthorized wse? Systems Documentation ‘After clletion of IT documents, documentation foreach ofthe IT systems was analyzed. The {IT Audit focuses onthe Billing Lifecycle subst ofthe Healthcare Delivery Lifecycle: Healthcare Delivery Lifecycle ‘This procedure outlines the steps necessary to audit the providers IT Healthcare billing sytem and determine how tis fraud/abuse is being perpetrated in the billing lifecycle. The healtheare delivery lifecycle steps include: 4. Bed ficilty; office service; products b. Presadmissiontdmission/office appointment ‘& InpatienvoutpatenvofTice services performed 4. Patient dischargedoffice visit concluded ‘Medical record assignment of ICD and CPT codes Bills processed and submited {Bills submited to TPAJpayer for processing ‘Payment receised |. Account follow up/olletion TT Billing Lifecycle ‘The IT Audit should consider the eror types listed above foreach step ofthe billing lifeeycle. At ‘high level, the IT ling lifecycle i as follows: ‘4 Claim is filed out by human either on a paper form or an electronic record that records Information about health cae item delivered toa patient. ‘An operator enters the claim data into the provider's billing system. The system validates the enres, checks eligibility and performs actions according to system settings 4. Thebilling system proceses the claim, updates the database and generates bill, Review of information technology (IT) systems is @ vital element of the audit process and included examination f provider IT systems, thee inputs, outputs, and processing. The purpose ‘CONFIDENTIAT Pasoae a few esa mill vatnarseet cee ‘ofthe IF audit was to verify iFevidence exists inthe IT systems and procedures to suppor the retminary aut findings. IT Audit Process PCG developed an overall understanding ofall provides’ billing operations and systems. PCG documented the workflow from the provision ofthe service tothe creation of a claim. To achieve this, POG: + Analyzed each providers healthcare information systems. This included all the systems that interact in the clei lifecycle, including intake, eligibility, prior uthaization, health ecords, and billing systems, as Wella relevant databases. ‘+ Performed a full review consisting of two major elements: 8) Analyzing how the systems and databases work; what rules they use; how they interact; and wio and built them, operates them, and maintains them. To this end, PCG requested all documentation regarding the information systems in pace. 'b) Performing end-to-end tests fr selected claims. PCG sought to folow claims selected for review across all systems end to compare system inputs and outputs for re-entered clsims data in order to verity proper system performance. These claims represented subset of the claims subject to clinical ease review. steps focused on identifying the followin factors that could ontribute to the bi “These au iregulri Weak security Unauthorized access to data and unauthorized emote access Inaccurate information and erroneous or falsified data input Misuse by authorized end users Incomplete processing and/or duplicate transactions Untimely processing ‘Communication system failure Inadequate training and support, General IT Findings Generally, providers were helpful in explaining how ther systems worked and in providing the requested documentation. However, because of system imitations and apparent software vendors contractual arrangements, there were several providers who could not provide the fll range of requested documentation, ‘CONFIDENTIAL PageHuman Services Deparment Betavine Provic Ant UIUC CONIA, eal Report awe mill Sia ‘The 5 providers audited use systems to handle thir intake, eligibility, clinical record eration, billing creation and billing submission. Some providers use more than one system e.g. a Clinical Records system and a Bling sytem). The providers use the following systems fer their clinical and billing functions: nasa ‘Border Area Mental Health Counseling Associates, Ic ‘The Counseling Cente, Inc. Families and Youth, Ie. Partners in Wellness LLC + Southwest Counseling Center Ine. + Valencia Counseling Services Inc cmc ‘+ Southern New Mexico Human Development EMR Bear ‘+ Hogares Ine. ‘+ TeamBuilders Pathways ELPereo: ‘© Youth Development Inc Medison: ‘+ Santa Maria El Mirador ‘Service Organization for Youth Inc. NextGen: ‘+ Presbyterian Medical Services ‘Anasazi Software was notable to provide a complete audit record for billing. The sofware provides an adequate suit tail for the clinical portion, hut aot or billig. PCO staff wae Jnformed, through providers, that Anasazi Software would not provide any stem documentation, claiming that itis proprietary. This inludes: User insructions/manuals/guides ‘CONTENT PeedSine of New Meio fini Haran Services Department @ ‘Beta Heath Provider Aus a ial Rept User raining materials Installation Instructions ‘System mainenance guides ‘System development documentation All providers utilize the Optum portal for authorizations, eligibility, and billing entry, and all providers use Optum Netwerkes a their ACH ~ Aulomated Clearing House. PCG evaluated all the IT controls involved in the billing process from intake trough to submission of the Claim during our audit. PCG found thatthe sophistication and controls in Place were greater for the larger organizations. Some organizations they were more reliant on ‘manual processes and institutional knowledge that had been built up over time, The size ofthe IT Potentially embed clinical management feings. to improve processes ‘+ Potential change in ranegement. Provider Overview Border Area Mental Health Services is the largest provider of behavioral health services in southwest New Mexico and has seven locations across the region. Within these locations, Border ‘Area delivers behavioral health services including outpatient service, family programs, substance abuse serices, comprehensive community support servicescase managemen:, and ‘community comection program services. PCG was tasked with reviewing several of these programs for compliance with New Mexico regulations Payer S$ Chims Paid FYI2 ' Claims Paid Audit Period ‘BHSD 1228308 ao) cyrD 85,398 78450 Medicaid FS. 48977 235 Medicaid MO 146,105 $069,573 nwo 15.598 120357 Otter 243511 m3 Grand Total 3081807 13a Audit Team Observations ‘© An entrance conference was held approximately 30 minutes after PCG arrived onsite et Border Ara Mental Heath Sevices CAMHS), MII was out of the office on the day PCG arrived and our entrance conference was | MMMM cssued responsibilty forthe coordination ofthe document colletion and worked with administrative and clinical staff. ‘+ POG began to receive case files onthe second day of our vist CONFIDENTIALa e fini ee ‘+ BAMHS staff provided PCG with hard copies of documentation and PCG scanned the files and saved them toa laptop, + MIMI supplied PCG with documents related to the BAMHS billing system and procedures and did an informal demonstration ofthe system. + Initially, BAMHS provided a user guide to Anasazi but upon consultation with the lisensor requested that PCG sign « document tht we would not distribute of view te ‘document for competitive reasons. PCG purged the document fom our files. ‘+ BAMHS was cooperative throughout the process but was disorganized in thelr collection ‘of documents. PCG received multiple copies of many of the documents and many documents were not submited, 4 Clinical Reviewers noted the following general findings: (© For Foster Care and Treatment Foster Cae, time sheets were often the only documents verifying placement of a child ~ no progress notes ot other gotl tracking documentation was received for review. O° (© SafetyRisk Assessments were not completed or upto-date for multiple consumers who were assessed to have curent or past suicidal ideation (S)), homicidal ideations (HD, self harm or domestic violence issues, © Comprehensive Clinical Ascoomonis were mot always provided 10 etermine/support medical necessity for the billed service or the provided assessments were incomplete of critical information, (© Treatment plans were missing, not up to date, andlor not individualized per (© Progress NotesRecpient Documents were missing, incomplete, end insufficient ‘of necessary information Random Date of Service Claim Review POG reviewed one hundred and fifty (150) random date of service claims for July 1, 2009 through Januery 31,2013. Below is a table showing the relevant programs tht were included in CG's random audit sample and the resulting findings: CONFIDENTIAL Peermill. Procedure ‘code Program Decrptin Foca alan ‘Oupatiet—2030 hates wer aime Chime 5 2 086 Owain 4:50 nats 28 Grand Total Specific Random Sample Review Findings ‘Oupaent—75-40 mates Family Thesey Group Therapy Medication Maageast Intesve Outpt Progra Mena Heath Asseent Foster Care(Stle) RN Medion Moicring Ci ntrveto evo Ho, 04 Fo—ccss Payee Rehabiiaon Mts emate They ‘Tretmen Foster Ce Family Stinson eves ‘ebay Hea Trent Plan Up Vane ‘Chime fine © ° en} ” ° «oo we mie ms 0 eS 120 0 re: moe re) as} 10 0 m0 we 8 wom se eno om Se nt elas nl Rp om eee ° oe ° tm oom om mm oom oom oom as oom oom °m% am 308 =m oom oom em rey aan ma For each program reviewed, PCG identified the level of complisnce and any specific areas of concer. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concem PCG Identified: ‘CONFIDENTIAL Paseo‘ayunaqnaoo ne i004 24 i004 slsls|sis 024 3/5 |s|/e\s\sis Z| 3 |2/s|s/sf S| AEE) aja BVA SE e/ Eu 004 3 ss Jeane suru sean so 3 z = gs |s|s/s s |s|s|s ayalaya aajayaeo ayunaiaNoouae swuNaaUNos ‘pe apo een ‘DNUEROS orang cnet {we STS Oo @ esteg ayuna@aNoo ‘cy pope penne pb g\s|s/8 a)s|s|s aE cen aladola a oem en S| patibriereapentitiny cata moN OOS‘AWuNacIANOD ‘say oes HE HE dD emu ap Bay “agate ana A 2 rt ‘mre po said wT saan 8 preg I 2000 Gs “ema es ‘s88i¢'¥ 901 sic owad-s800—m4 NOME |avuNaauanos are] ng) ua waa EOL “eon aarp Bas “SN PEP = ase RL “bse vena ond aro 4 5 ETE G8 Oo pou s|2|s|2 3/3/35) BP) al\el|sis g/3|3|3 "aa ae im ers Ss (lon eG) ou ate pe O011-9.00 21H “Payson amp tr TOK Bos a 0 pin sem aarp i nl NA Soret | | oe ne on vara eso, “eae se megeyero ag 62a 5 > elven seman USESa fall 7 URC gpI Setar Hath Provide ats Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represens the characteristics of that population, The goal of sampling isto determine the qualities of the population without examining all the ements in that population. Random selection of claims is necessary in order © produce valid sample. In random sample, claims are selected from a population in such e wy thatthe sample ‘is unbiased and closely reflects the characteristics ofthe population. Sampling Frame Size: Total umber of claims from universe of elaims from which the samp! was selected, ‘Sampling Unit: The entire claim amount ‘Time Period: 7/1/2009 ~ 1/31/2013, ‘Sample Size: Sample size is 150 claims. Extrapolation: The overpayment was identified using the lower bound ofthe 90% confidence interval ‘Border Area Menta Health Services Sample Ste ae 150 ‘ota Paid for Sample si4o3 Sampling Frame Size a [amber of Sample Claims with Overpayments “ ‘Teuv Oveprment Ug Lover Bond ote 90% Sas Longitudinal File Review PCG selected between one end five of high risk procedure codes at each reviewed provider and ‘then selected the fve recipients who accounted forthe highest collar billing associated with each Selected procedure code. PCG then performed an administrative and clinical review of 100, percent ofthe claims associated with ech selected procedure code and recipient which were paid billed for, and what HCPCSICPT code should be assigned to the service, using the service provided and start and stop times of the service. ‘The service is processed by the Anasazi system and transformed into an 837 billing format, ‘ich s uploaded to Optum heath through the Optum Netwerkes system, TT Contacts and roles Pagett cu eal Sa ne | fil Siu of New Mexia Application Controls -System Walkthrough Administration and Segregation of Duties User Roles System Admin Groun: Can add wers and configure datasheets fr health plans and services. “Administmtive Group: Can configure datasheets for health plans and services. Medical Records end Intake Groups: Records Clerks and Intake Staff have appropriate administrative levels of acess wo ecords (primarily administrative and demographic records and read ony for linia information) Clinical Group: All tnisins who bil ae inthe Clinical Group. They can ener clinical service provision othe system, COI Group: QI Manage is inthis group. ‘Glnical Supervisors Grows: Clinical Supervisors. ‘Biv Grande Supervisors Group: ‘Supervisory staff from Rio Grande Behavioral Health Service are provided with supervisory roles due tothe management services agreement with Border Area: 1 2 3 Auuitors Group: No staff at Border Area curently have the Auditor Role, but Border Area has ‘established four Auditor accounts should auditors need access, Strengths and Weaknesses Strengths: + The Anasazi sofware offers sequestration of clinical information so that users' roles determine the kind of information each usr may have accesso ons per client basis. For example, «font ofice cle may have access to certain demographic information. Each einician enters his ova billing information + Anasazi software allows for members of group therapy session to ative and leave at different times, allowing fer more accurate billing of group services. aa anil ee ‘+The Anasazi system that the provider uses records and tack clinical records. ‘+ The audit tal for the clinical record portion of the system is extremely complete and easy to generate. ‘+ Have extensive tuning and training videos for Anasazi system. Have a training database ft up septate from the production database. ‘+ The IT department has written 50-100 reports to check different medical field billing value accuracy tht they run on all entered bill before they are submitted for payment. ‘+The isan audicalforthelr IT helpdesk issues that have been resolved. ‘+ Have a disaster recovery plan. Border Area Mental Health experience a fie @ couple of ‘years ago that destroyed the majority of their paper records. Since then they have Intute a strong disaster recovery plan ‘Weaknesses: + The point of entry othe claims payment system provides the ability to change any biling fiom what the clinician entered. The 837 ean be changed when connected to Optum [Netwerkes. The person uploading the 837 ean make any changes to billing with no audit tall ‘+ The point of entry tothe claims payment system provides the ability to change any billing, from what the clinician entered ‘+The Anasazi system does not report on the audit tal for he billing part ofthe system, ‘© There is no complete audit til of the entre clinical and billing transaction that is {guaranteed to correspond to what is illed to Medicaid Recommendations ‘+ Create audi trail for any changes made to 837 fles when they are uploaded to the clearinghouse. Pageil il ste fnew Mon Human Seve Deparment unk says esi Pei i, Enterprise Audit Provider Specie Methodology PCO utilized a consistent, systematic approach to conducting the enterprise aut of Border Area “Mental Health Services (BAMHS). PCG began by locating BAMHS's legal entity, ts officers, ‘and organizers. PCG also reviewed iil founding and leadership information on BAMHS. CG located and reviewed BAMHS's audited financial statements and tx data, PCG recorded and reviewed reent officers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and ‘analyzed both the parties and the relationships, reviewing fr potential conics of interest POG assembled the financial data and analyze it, looking at key ratios, ends, and tracking variances. PCG wacked the organization's addresses end reviewed ownership of property online ‘or through the ecunty assessor's office. Finally, PCG peeformed media and court record searches (on the organization or related individuals Because of the closely interrelated companies, PCG reviewed BAMHS and two other related companies simutaneously ~ Mimbres Regional Mental Health (provides administrative staffing ‘to BAMHS) and Mimbres Properties (leases realestate to BAMHS). ‘Audit Observations Border Area Mental Heath consists of three related exempt organizations ‘+ Border Area Mental Heh Services (BAMHS); ‘+ Mimbres Regional Mental Heath (RMI); and + Mimbres Properties. Of the three, BAMHS isthe provider organization; MRMH isan orgnization tat provides smiisrative staffing to BAMHS; and Minbres Properties leases realestate to BAMHS. In dition to leasing real estate to BAMHS, Mimbres Properties ha significant unrelated business income inthe form of rental income. aeani fur cONSING Ste of New Mesico Human Seve Departmen Behavior! Health Provider Aad Pal epee [BAMHS publishes the least transparent financial documents of all the organizations reviewed. There is extremely weak disclosure of pertinent information for evaluation purposes. “These three orgatizations are governed by three separate board of trustees, however, with small ‘exception; the tstees are the same individuals. These individuals do\not appear to have financial connections with the organizations Key Staff Frank ‘Van Gundy | Director Patricia Chavez Secretary Treasurer ‘Margaret Vesper Diresior Sem Tapia President Chie Leonard | Viee President SE Patricia ‘Chavea. ‘Margaret Vesper ‘Sem Tapia Claire Leonard Helton Leonard Vesper Tapia Chavez ‘Financial Relationships All three organizations have significant transactions with local company, Atlas Resources, although there is some vasiance in annual reporting with ths contactor. Atlas Resources isan ‘employee leasing organization, NMSCC 1570209 located et 2009 Eubank NE, Albuquerque, [NM and owned by Jimmy Daskalos and Nick Kepnson. Both men are involved in a number of companies and restaurants in the Albuquerque atea and have a numberof realestate holdings. ‘They purchased the former Lovelace Hospital property and have subsequently leased the raeaS Anil anne ‘eter al rove Ae Fal Report property. At one point, local media reported thet the facility would be leased to physician practice groups. BAMHS contracts with Rio Grande Behavioral Health Services, Ine. (RGBHS) forthe provision ‘of accountng, billing, atd human resources, Unlike athe provider organization, amounts paid by the organization to RGBHS for these services are not disclosed. Rio Grande is a provider sponsored network and each organization's board members serve as rotating members of the [RGBHS board, While Rio Grande Behavioral Health Services receives montly fees from its members, RGBHS has also distributed various grants back to its members. In addition, BAMHS may contract with Rio Grande Mangement, LLC (RGM), for manegement services, although it isnot disclosed in financial documents. These likely inclu legal services, and the provision of exzcutive management. Providence Service Corporation fully owns Rio ‘Grande Mangement Services. Providence is a large, for profit, national, corpeation providing ‘government sponsored social services directly of indirectly through managed local entities. Providence's network originated in Arizona and has developed a network of providers serving 70,000 clients inthe US and Canada. Typically the executive director ofthis organization would bbe an employee of Providence Service Corporation. Kathleen Hunt isthe Executive Director of BAMHS. She is also a director of RGBHS which is typical for members of the Rio Grande provider group. For thes reasons, we believe that she is likly tobe employed by Providence Service Corporation and that BAMHS contracts with RGM for her services as well asthe afore ‘mentioned management services. ndatiows ‘Summary of Fadings and Revo Because staffing is paid by Aas Resources, | Ths is highly unusual an iti recommended ‘compensation isnot disclosed in reports that| hat MBRMH be required to disclose ‘exempt organizations typically file. ‘significant compensation by individual leased through Atlas Resources. Those individuals should be reviewed for associations with ‘other organizations ad individuals. 1k is further recommended that Mimtres Properties disclose detailed source information for unrelated rental income, including ena, leases, and ash recep, [Major contacs, such as those with Rio [Full disclosure of all sigiiant conracis Grande Behavioral Health Servizes and Rio | shouldbe reported on the organization's Form Pier== Grande tanagement are presumed, but not [ 990, fully disclosed List of Key Documentation Reviewed DocumnentSouree Year (fapplicabley “Audited Financial Statements BDz Provider Organizational Chart ‘Curent {Form 390 (Noaprofit fils) 2012, 2011 ‘Federal Tax 20 Feetail unui CONE. Batance Stet Aes (Cash nd eqivalens (rats and Cont Retabe Note Recetable Fur ed Fstures Les depreciation “Tota Aste bier ‘Acsounis Payable Bulag Fund payable Gans payable ‘Annual Leave payable “Tota Libis 1 Linles and Net Assets 5 290n48400 5 69124600 5 axtassoo rt) 5 (67478000) s 4ss4onaae 1494ea00 30618800 9352380 10623400 s 14s7esn0 5 283692400 441400 Se of New Meso Homan Senies Depart ‘eta lh Provicr Audit Fl Rept Fanamiccoyentnc havior Heth rovig: As "a Report Income Statement 200 Revenue Belwvor Heath Services Diviion —$ 1297,30200 Chien Vout and FanisDep —$-653.81800 owe Granted Comets 5 1021,6400 Progam Feet 3S La8ls4t00 nae ome 5 Rane Ne Asset ree s ‘otal Revenue 5 48662700 Hipenses Program Servet 5 44006000 ‘Toa Eepenser 5 4s0363.00 Change a Net Ase S ssegrn00 Net Assets, epaning of year 5 246024600 Net Assets end of year 2361400 PaceCounseling Associates Inc.a fil vate ric consutn rl Repo COUNSELING ASSOCIATES BEHAVIORAL HEALTH PROVIDER AUDIT. Case File Audit Dates of Onsite Review arch 613, 013 ‘ain Point of Contact a Felty “Extrapolsted Date of Service Overpayments ‘Actual Longitudinal Overpayments Total Overpayment ‘Scorecard results ae as follows: CAST ssid Compliance Rate 65% 15% Steicot Content > AI “This scorecard result ranslates tothe following Risk Tier: Tapes Finn ETAmint waterline run CoN al Repo 3 ifiant facings, + Provide taining and clinical’ including signeant assistance as needed. quality of ere “+ Potentially embed clinical management Findings. to improve processes. Potetial change in management. Provider Overview ‘Counseling Associates, ne. is the largest provider of behavioral health services in Chaves and Eddy County, New Mexico. Within these locations, Counseling Associates delivers behavioral health services including; outpatient services, comprehensive community support services (CSS), mul-sytemic treatment (MST) community correction program services and substance abuse services. PCG was tasked with reviewing several of these programs fer compliance with [New Mexico reguations. Payer ' Claims Paid FYI2 ‘ Claims Pald Audit Period “BHSD 1257683 wi) cyFD ean 24513, Medicaid FS 39333 81,07) Medics MCO 1692032 5082958 Neo 220 aT Other 2581 3si7 (Grand Total 3078200 9a0347 ‘Audit Team Observations * Upon PCG's arival at 9 +, ET was ot CAIs Crist site. The PCG audit lead was notified that MMMM wes traveling back to Roswell ‘immediately. The entrance conference tok place late morning ‘+ CAT saffimmediately began to compile the documents. PCG received its frst documents inthe afternoon of Day 1, nd received documents steadily during the onsite audit. CONFIDENTIAL Passin| Horan Services Deine i ‘ste of New Mesa Betavira! Heath Provider Sate runic conga inal Rept ‘+ Clinial Reviewers noted the following general Findings: Random Da Sefety Assessments were not always completed for consumers who were assessee to have curten o past suicidal ideatons (SI), homicidal ideations (HI, se are ‘or domestic violene issues. Safetylrisis plans were often completed months after the iil assessment wher the concern for safety wes revealed, Diagnostic Reviews often showed conflicting dates (difference of several month) ‘elated to completion and authorization signatures by clinician and supervisor (Comprehensive Clinial Assessments appear not to be up to dat with current information. ‘Treatment plan were not up o date and individualized per consumer. Progress Notes Recipient Documents were inconsistent sross staff and programs. te ofService Clim Review PCG reviewed one hundred and fifty (150) random date of service claims for July 1, 2009 ‘through January 31, 2013. Below is a table showing the relevant programs that were included in 1G ndom nd supe the rething dings Pecan pag Duron Chine Chinn CMM Gigs %Chme Revered _ Revered rate BEES. a aa 51 Open Soins a Dit Fey Thee A SRC TNS sm) Oop They boom 88am Ce “SM Offe!Outpstient Visit B o o 0.0% iS oaee l= ee 13) Men Ae Sete tore rciiit ene Hoi ANMetenn niet tp atm ‘CONFIDENTIAL Peer?a at St of New Mexia il Il resin Reese hose vata Seas ran ahs et Tail ani Neagmetne a iis) Hongo a) ae) A ‘oi? PodomidRcbiion =A RED ns Sere Eee Pe (as) MalisymoncTomy = tk ovis Tati ecos 2 ea tare a eee tier Bemis sas stm ates iacea nse se Grand Tt 19 tessa Specific Random Sample Review Findings For eath program reviewed, PCG identified the level of compliance and any specific areas of ‘concern. Below is a uble showing each of the non-compliant claims PCG validted, the season(6) why the claim was found to be out of compliance, and the area(s) of concern PCG identified CONFIDENTIAL Peercata ‘IvuNaaLsNOD “gous poe ala NE oda ent ‘npn pou rey OERws | s all ail =?‘IWuNaaIANOD seg | see | seg | es som es fms | ms a | sir i ei [es | oe | oe som see | ema | ome | seg 1m ei foes | om ms som pasa 0 soma S00 mG PEE pa tee ene ee sue wes | ora | om | oma si sea | wa | omy | omg iorswaste ‘VUNaaLsNOD Sa ea “Pa RUE RS V Bp bap eqnexe neues pay Ys 1pm er Ny purcpiauscar ay sere ionogar ame | wi | wn | yy | ia way | sm Rs shoe buss poy Sab ral geo ona orto pane Meus ee SL "pmiouDoy SEES a seedy roe aus UTES ‘pose pe un aqua ys wef | see | ow wi | ws | om sie aay fineep mure hie agoue ps e surnam ena) FaU—UEp eo RORY paounpprenenaewpeamausatdy| mw | wm | wm | my | w | me | ms | aw | ome [sox a wef iw [om [ie [ow [om | oe | me | ome ioe EEE 9 piucoper scam Nee umm ra njsimuran ios pusmeuepoy| YN | YW | WW | Wd | ww | es | i |W bi Eel um oun Gey Rae mgs wn sue we me epueodounomusonrneinoiepay| | W™ | W | wd | Ww | sed | 4 | ted “we | ons soca! md och rs rs 00 i : 5wow fom | ose} oes | my | sea | oer | 0 we} ow | ow | sea foes | se | ee | ms a ‘00 oop ae SII race 2a ren otra naa unr a ey uu ‘sneeonatupamppemeiccreu wm | w | m | om | m | w | w | w ‘as usa cesure PCC undescd the ovumenation ia te eos «Hops stapled al he request consumer and sf oconenton. Al ected consume dctmens were coset ting ough PCG ses be cane Some of the files were electronic; however, Hogares staff printed hard copies for PCG to scan. CONFIDENTIAL @rill Sees Report + The majority ofthe consumer and staf documents were provided over ton days. A few of the requested fle were provided later because they had tobe retrieved from storage. + On Wednesday, Febrory 278, PCG's IT Lead, Mike Distr, et vith I to review thei tiling and clinical ystems, including ips outputs and audit ls ‘+ Hogares staff was always prompt in responding to audit tam requests fr clarification or addtional information. ‘+ Clinical Reviewers noted the following general Findings: © Comprehensive Clinical Assessments did not always suppor medical necesiy for the billed service or the provided assessments were incomplete of eid information forthe dat of service under review. ‘© Treatment plans were missing, not upto date, andlor not individualized per consumer. (© Submitted treatment plans did nt always cover the dates of service under review. (0. Progress Notes/Recipient Documents were missing, incomplete, and insufficient of necessary information. Random Date of Service Claim Review PCG reviewed one hundred and forty seven (147) random date of service claims for July 1, 2009 through January 31, 2013. Below isa table showing the relevant programs that were inched in PCG's random audit sample and the resulting findings: Frecedare Program Depa ———Wol—SValoe Cains SValee Cais inns Chim Fall Cis Reviened_ Reviewed Fale ee a Evalaton 50504 Outpatient 20-30 mines 1 a ° oom 90906 Oupaon 45.50 minster aaa rego 0 ons 9087 Funly Therapy bo om 59053 Greop Temps 3 a ° oom 21062 Mien Management 2 we oom iors Transco LivngSewios = 1500 oom Reng‘Ste ofNew Menico will ntl Human Services Deprinnt Behar! Heh Provider Aas Punk CASING nal Repo a irae anpemer ne—————9 a ants) HO; HN, HM=Ccss RT (QS014—Teleea Facity FeeCode 5 mm © (mK ‘SSH Treen For Ose yy oom 71005. Resp Servis ows 0 oars crwea Her 14478) a HOR ERK) Total ‘Specific Random Sample Review Findings For each program reviewed, PCG identified the level of compliance and any specific areas of ‘concer. Below is a table showing each of the non-compliant claims PCG vadated, the reason(s) why the claim was found to be out of compliance, and the area(s) of coneem PCG identified: CONDE Pee Pa‘TvuuNacusNoo Es t ie & Hal z = z i z i z i 5 1 ‘Lapras MoNd DAL a es fw] ows | wo] om | oe noes ie (ioe @ @ @soa HOUR 8 pe eWauEN ALC me ea soap ep san oop e veg ge! isco {gt pS a 9 de HSH pee 2 snp orc se we eyes psn smash ce 2 8 pes OLS ur oe ano i og Shs 050 SD {gu Bae su am tL) 90048 TYong ‘avuNaaisNOD apd pare em een arc s s 2 i ore I 0 "wom on no od a 2418/3000 s |s/sl/s s |s/sls |< le/els s|sisls availsa i s /slsls|s gs sisls|s abate eswlow [ow [ow fw] oe | oe | om, =e sion wlom | ow | ome | ow | see | ome | oe | ome sox we} owl ow | wef w]e | es | sme | ome som wow {om | see] w | see [om | ome oa | sto |* | ee ‘| wy} om | ow | ome | mw | os | wee | oe oma |] ‘soe | | wef fom | ms fo | om | om | wee | omy ston we fiw [om [me tow |e | see [mea oe somiil il ii tomate ‘Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristic ofthat population. The ‘goal of sampling is to determine the qualities of the population without examining all the ‘elements in that population. Random selection of elaims is necessary in order to produce a valid Ia candom campo, claime ae eolacted from a population in auch a way tat the sample is unbiased and closely reflects the characteristics ofthe population. ‘Sampling Frame Size: Total numberof claims from universe of elim from which the sample ‘was selected, ‘Sampling Unit The entire claim amount. ‘Time Period: 7/1/2009 ~ 1/31/2013, ‘Sample Size: Sample size is 147 claims. Extrapolation: The overpayment was identified using the lower bound of the 90% confidence ierval Hopes oe. Sample Soe Te ‘Tota Paid for Sample sisave ‘Sampling Frame Size Hie ember of Sample Cains with Overpayments 2 “eatative Overpayment Using Lower Bound of the 90% 33629976 Longitudinal File Review [PCG selected between one end five of high risk procedure codes at each reviewed provider and then selected the five recipients who accounted forthe highest dollar billing associated with each selected procedure code. PCG then performed an administrative and clinical review of 100° percent ofthe claims associated with each selected procedure code and recipient which were paid “CoNADENTIAL Paarahi sect ‘Behavior! Heath Provider Aue FUNC CoNSING "nal Repo ung calendar year 2012. Below is «table showing the ralevant programe that wer nehaded in CG's longitudinal fle eview andthe resulting findings: te takin talc Aileen cee UE ae a) reins "i — pee eee ae aaa ae wom as vom 10104 mum a se ee Provider Credential Review For all random date of service claims and longitudinal files reriewed, PCG requested provider ‘credential information foreach ofthe clinicians or other staff tat had rendered the service. The table below shows the numberof staff reviewed by provider type: Provider Type Reviened "(Community Support Worker 5 Therapist 2 ‘Communty Support Worker Supervisor 1 Payee ‘ Bas 1 Residential BMS, Respite, Other s Tesi 2 ‘Therapeuti Foster Care Stat B Uaknoww/Otker re ‘ota Staff Reviewed 9 “CoNEDENAL Page 50as oe mill ea Human Senices Deparinet ‘Betavio! Helh Provider Aa rureic cong N nl Repo TT/Billing Systems Audit System Overview Hogares uses EMR Beat as their Electronic Health Record and Practima as thee biling system, ‘They interface wit the Optum Netwerkes ACH to submit their bil-or processing and payment EMR Bear is accessed remotely to allow progress note updates. Prectima is used for case tracking and billing. Practima is based on industy-standard Microsoft technology and the database is MS SQL Server, also an industry standard. Emdeon is 3 party system used to check eligibility. Netwerces i used forthe billing clearinghouse. IT Contacts Strengths and Weaknesses Strengths: ‘© Have an EHR system that they us to record and track linia recorés + Alluser are trined on the software system, + iret access to software system author III fo isues or questions # MIMI is « song developer and very knowledgeable abnut this subject area ‘Very qualified to write software for case tracking and biling process for behavioral related claims. Haye a proces for backing up the sytem database Have strong elabilty checking process, traning and system (uses Emdeon). Have strongly documented intake proces for new patents Have strongly documented process for submiting bling elms in batch process on regular basis to avoid dupictbiling ‘+ Have song system reporting capabilites to review payments, population treated and ‘othe clinical activity aross population cross sections ‘+ Have a hard connection between EH system and billing system. Data entered int the EHR system is uploaded into the biling system on anightiy basis “+ Have a strong process for adding new employees and deleting employees that have been terminated. ‘CONFIDENTIALe Hil ESS + System appears to be a strong application for submitng claims correctly with sccuate pricing. System does contin reports and open database to corroborate billings with progress notes Weaknesses: ‘+The point of entry tothe claims payment sytem provides he abit to change any bling from what the clinician entered. While this has not been observed it isa considerable weakness BIBI ne onty programmer and is the only person who knows the software system from begonng 10 end. Hogares has no beck fr. They re looking at lteratvs to Bho support hei report requests 4 Te process for checking thatthe data transite frm the EHR system to the billing system i eoret is weak. A file from EMR Bear is eretted and loaded ino Practima, “There is no report or comparison done to ensre that everything that was taken fom [EMR Bear was raafered into Practina preci. @ Recommendations 4 Stould develop regular process report to vel tht dat moved fom EHR to biling system isalvays comet + Newt fnd lara sure fr suppoting tom ination othe ely aff menber ‘ho baste necessary kn ow ‘CONFIDENTIAL Paesa nal won ‘bavi Heath Provider Andie FUR CONSUL Fa Repo Enterprise Audit Proviter Specific Methodology’ PCG utilized a consistent, systematic approach to conducting the enterprise audit of Hogares, fe. PCG-began by-loatingHogares: legal enityrite-oficers, and organizers. PCC alo: reviewed Inka founding and leadership information on Hogares. PCG located and reviewed Hogares" audited financial statements and tax data. PCO recorded and reviewed recent offers, Key employees, and independent contractors. PCG also searched for ‘ther entities ovmed by key emplayees and contractors. PCG located related partes and anclyzed both the partes andthe relationships reviewing fr potential conflicts of interes. PCO assembled the fnmncial data and aayzed i, looking at hey eatin, wend, and Uacking, ‘variances. PCG tracked the organization's addresses and reviewed ownership of property enline ‘or through the county assessor's office. Finally, PCG performed media and court record searches. ‘onthe organization er related individuals. Audit Observations Hogares is along standing New Mexico non-profit providing serves for troubled youths and ‘heir families. The organization provides residential and outpatient services, foster care and sdoption services as well as transitional ivng skill, ‘At 63012010, the organizatir had audit indings related to internal control; these were resolved st 3020. Kg Stall Bill Tito Pama Katy rary Herb Tort ‘CONFIDENTIAL Pase it i ed uC CONING Eawinde Reyes VF ‘Staveley ‘Board member Perea Board member Peters Board member Nancy Jo ‘Archer CEO Larry Leyva Fiscal Ofer Nestor Baca Board member Kris Carrillo Board member Matthew Glickman [Board member Erie Burgmaler ‘Boord member Financial Relationships ‘The organization as a service agreement for child psychiatry with TeamBullders Counseling Services. @ ‘The organization paid Zia Behavioral Health approximately $11,000 in 2010; $148,000 in 2011; and $231,000 in 2012. Zia Behavioral Health is owned by Shannon end Lorraine Fredle, builders. the Chie Executive Officer and Chief Clnial Officer, respectively, of Tes ‘Summary of Findings and Recommendations Fanti ‘ist of Key Documentation Reviewed! “DocumentSouree SS Year pica) “Audited Financial Statements SSS TOT, DOT Provider Organizational Chart Current Form 990 (Nonprofit filing) 2011, 2010, 2009, Contracts ‘Third party contracts Tndependent sontractor agreementsae series iil | oe a arf al ea a eT seer en ee enter eae ree epee ee apamentne_}._-—_4_am_t_gam_t_nate San nee ree ee sere ee eg ee ceva Sean eee ne ee scree alin cee ne laa eee este orem Potenlly embed clinical management tw imgrove processes. ‘+ Potenal change in management Provider Overview Pariners in Wellness is located in the Albuquerque metropolitan area, Within this location, Partners in Wellness delivers behavioral health services including substance abuse treatment services, mental heath support services and community suppor services. PCG was tasked with reviewing several ofthese programs for compliance with New Mexico regulations Payer Claims Pad FYI2 ‘Claims Pld Audi Period BHSD 386 121900 cvro 1420 18062 Media FS 17,703 334 Mediesid MCO 25159 356345 nas su ° ° ses03 281388 ‘Audit Team Observations An entrance conference vas he vith ‘immediately upon the audit team’s aval onsite. © MMI sai “superuser” (backup for thie primary IT staff person who is located in Hawaii), walked the team through the clinical records according to name and DOS and explained the format ofthe records. ‘+ The majority of documentation was provided electronically via tansfer of files to a thumb drive that was provided tothe audit team, ‘© Clinical les were provided in a combination of paper and electronic format due to signed consents that are documented on paper and then moved to an electronic format. ‘CONFIDENTIAL Page‘Sate of New Meco e@ fat ll Honan Services Dosen Behavio! Heth Provides Aas ee ‘na Report ‘+ Client signatures on treatment plans were done on shard copy. Staff didn’t have time to pull the hard copies and noted that at times the electronic signature pad was down and lions coulda’ use it ‘+The team did not have access to records for employees who were originally stationed at the Carlsbad provider site, + Glnica! Reviewers noted the following geveral findings: 1© Comprehensive Clinical Assessments were not always provided to determine/support medical necessity forthe billed service or the provided assessments were not Up to date forthe date of service under review. © Treatment plans were missing, not uptodate, andor notindividualized per consume. (© Progress Notes/Recipient Documents were missing, incomplete, and insufficient of necessary information ‘Random Date of Service Claim Review @ ree reviewed one handed and fy (150) random dat of service claims for July 1, 2009 ‘hough Jnr) 31,201. Below it able showing the lean progam tht ware ide in CC's random aut sample and the resulting findings: rest egram Dap Chis Chin svned_ Reed or eae ea ie oy Petite Drie 2m 88mm fae lose Saba =e) oy aan ee a faa sies a) ial aww 7 Fey They tome eam Fis Gop Tay ee Og as set MekaimMimaenet, == $M fiwis| inn Ownimnroee om CONHDENTIAL aae ii | Sate ofNew Mexico fll a iM I salsa ae Ea ie ae oS cena ne hn > aE oo cm arr ‘Specific Random Sample Review Findings For each program reviewed, PCG identified the level of compliance and any specifi areas of. concer. Below is a table showing each of the non-compliant claims PCG valiated, the reason(s) why the claim was found to be out of compliance, and the area(s) of eorcem PCO identified: ‘CONFIDENTIAL Tetote ‘Twuxsatsioo stimesp putt gn Baar eimong ideas | YY | MM | wf sea | md | ww | ow |g 7 el 5pm 9g Suc pure sn Leer cod aywrmourep sacra ogen fur uevonunyiniag | YM | WN | Mm | ms | ww | ww | ww | ed ud ee, zneee wummdiemaconoweveoven| mw | mw | wm | es mw | mu | w | sw | mee sie Taree av 7 pour son spay muon F163 vA 7 7 sme we bapa psp ee we} om {ow fom | w]e | me | sme | ay coal EU NSD sO oe I OH ‘tocar mipewenvommmincnon| ww | w | ow | wa | w | | ws | ad | me sige -wovlgemnetiessuna| ww | wi | ow | wa | wl ee | se | oe | mee sien “Tana oa wo, ST USN Sooo dmecrapanouen || mone | womceansgasmdiey scion | yy | wm | wy | ma | w | ms | omg | omy | omg sioctState New Mexico mm ontansnse Se UMN i Sampling Definition: Sampling is a statistical technique designed to produce a subset of ‘elements drawn from a population, which represents the characteristics of that population. The goal of sampling is to determine the qualities of the population without examining all the elements in that population. Random selection of claims is necessary inorder to produce a valid sample. In random sample, claims are selected from a population in such a way thatthe sample {is unbiased and closely reflects the characteristics of the population ‘Sampling Frame Size: Total number of claims from universe of elaims from which the sample was selected ‘Sampling Unit: The ene claim amount. ‘Time Period: 7/1/2009 ~ 1/31/2013 Sample Size: Sample size is 150 claims. Extrapolation: The overpayment was identified using the lower bound ofthe 90% confidence iteval, Partner in Welnes Sample Sta 150 “ota Paid for Sample sisaie ‘Sampling Frame Ste 2364 ‘Number of Sample Chis with Overpaynents ° “Tentative Overpayment Using Lower Bound of the 90% ae Confidence interval Longitudinal File Review OG selected between one and five of high isk procedure codes at each reviewed provider and then selected the fve recipients who acounted fr the highest dalle lng asncinted with ach selected procedure code. PCG then performed an administative end clinical review of 100 [eteent ofthe claims asociated with each selected procedure code and eipient which were paid CONFIDENTIAL 7 Pageunuc cons during calendar year 2012. Below isa table showing the relevant programs that were included in CG's longitudinal file review and the resulting findings: roe Fromam Fol Caes#Cains— $Chime 4 Chine ‘Code Description Reviewed Reviewed Reviewed Failed A lesen Grand Toa s ms ake Provider Credential Review For all random date of service claims and longitudinal files reviewed, PCG requested provider credential information foreach of the clinicians or other staff that had rendered the sevice. The. {able below shows the number of staff reviewed by provider type: ‘Comfy Sport Series Coordinator(C8SC) Commuoity Support Worker(CSW) ‘Total Staff Reviewed 2 Provider Type ‘Reviewed ‘Community Support Worker 2 ‘Therapist 6 ‘Clnea Supervisor v Pryeblatrst ' Hl 1 ComperTat Papefinn ee rie Cons ING ial Repet TT/Billing System Audit System Overview Partners in, Welloess (PIW) uses the Anasazi application which provides a wide array of components in sfexible display. Anasazi data resides on a Windows-based Server that exists in ‘firewall subnet on an internal LAN. Client Data in realtime which allowing for streamlined ‘quality of care ‘The Anasazi system is used by all of the Rio Grande Network, and while eae administered by the individual agency, the differences ae really superficial, such as: ‘The way menus are customized tobe displayed per the user roles, How user roles are defined, ‘The customization and scheduling of reports and \When certain aystem enhancements ae implemented in each agency. Individual agencies can decide what system upgrades are implemented and in what order. Most ‘agencies in the Rio Grande system stay one to three behind the most recent release. Each site generally deploys the updates to development installations to test and verify the updates before they are deployed into production. {In mos situations staff may choose the Anasazi data they wish to display, and may make ‘changes to ths display on-the-fly Broad funetonaliy i included that provides staff with ready access to information regarding the Client to ai hrw/her in preparing for different sessions. ‘Application also covers functionality that is common tall ofthe assessment and treatment pla assignments client bling, client payments). CCinician's Home Page functionality: ‘Clinical management complexities ll solved ina single sereen ‘© Overtwenty different views to choose from, including clint photos + Special supervisor acess to monitor staf productivity Client Data System functionality: ‘+ Service Test Recalculation Utility ‘+ Robust Reporting ‘© 837? & 8371 Claim Submission CONFIDENTIAL Pa 6il anil Pinta runt const ial Repo ‘+ 835 Electronic Remittance Advice ‘© Automated Billing Modality nd Service Code Assignment ‘Anasazi would not allow PIW (nor any provider) to disclose any training or systems documentation to our auditors, claiming it was proprietary. IT Contacts: Application Controls System Walkthrough ‘Administration and Segregation of Duties, ‘Agency Adminisrator Role: Can add users and configure datasheets for health plans and ‘Adiminisative Group: Can configure datasheets for health plans and services. fn ga Can conver clnial information int biling information of 1d by clinical eubord Service Provider Rol; Al clinicians who bill and are on the payroll hav the Service Provider Role. Auaitor Role; No staff at PLW Counseling Services currently have the Auctor Roe TT Strengths and Weaknesses ‘Strengths: ‘+ PIW clinical and billing sytem uses the Windows-based Server that house both the presentation and database layers ofthe Anasazi system are dynamically updated weekly to ensure the most current Operating System is in place, The Arasazi DB, and related software, s updated and msiniined onan as equeste/requred basis. CONFIDENTIAL PagesT ‘State of New Mexico mill oalsanicantoet rene cons al Repo. ‘+ PIW uses Intrusion Prevention Services (IPS) which are provided by the NSA 2400 firewall that separates the Anasazi Subnet from the rest ofthe LAN and Internet, These database signatures are dynamically updated on a daily basis to ensure industry standard currency is obtained. + Anasazi Sofware has a single-source-code system to allow for ongoing customizations andenbancerents. + PIW presented disaster recovery plan forthe application hosting server and electronic record ‘Weaknesses: Currently PIW IT staff have litle knowledge of the eppliction transaction and database ‘transaction logs +The point of entry to Optum Netwerkes provides the a ‘what the clinician entered ity to change any billing from Recommendations + Work with Antsazi vendor to understand the database and application transaction log. “+ Should develon appropriate accounting entrols for charge entryfbilling in Optum Portal and Optum Nesworks. CARDIAL — Faseail ns All Behar els Pee dts RULING il Repart Enterprise Audit Provider Specie Metodology PCO uilzed a consistent, systematic approach to conducting the enterprise audit of Parners #1 Wellness, LLC (PIW). POG began by locating PI's legal entity, it ofGeers, and organizers, OG also reviewed ital founding nd leadership information on PIW. CG located and reviewed PIW"s audited financial statements and tax data, PCG recorded and reviewed recent offices, key employees, and independent contactors. PCG alzo searched for ‘other entities owned by key employees and contractors. PCG located related parties and analyzed both the partis and the relationships, reviewing for potential confit of interes. PCG assembled the financial data and analyzed it, ooking at key ratios, ends, and tracking “variances. PCG tracked the organization's addresses and reviewed ownership of property online ‘or through the county assessors office. Finally, PCG performed media and court record searches ‘onthe organization or elated individuals Audit Observations ‘The oxganization was formed in 2009 and is “dedicated to providing behavioral healthcare and ‘other administrative and managerial services to health cate providers in the State of New “Mexico.” The organization is a parnership between Presbyterian Medical Services, Casbad ‘Mental Health Center nd Teambuilders. Key Sut Steve Director Doug. Director Toba Director Noel Direetor ‘Shannon Manager Trine ‘Manager CONFIDENTIALTil ini one Stet PUMIC CONLIN imal Repo Each organization paid in capital to erm the company and has been receiving a share ofthe et Carlsbad Mental Health Center bas received the following payments from the organization: spproximetely $333 000 in 2010 ad $732,000 in 20. Summary uf Findings and Recommendations “These services are primarily funded through Medicaid and the Sule of New Menieo. TR Tn ‘One member, Carsbad Mental Health Cente, | Adequate internal cntrols over hiling should ‘notified the organization that it plenned to | be implemerted, ‘withdraw afler agencies of the State of NM alleged that there were billing iregulrities in its own business and subsequently suspended ppeyments to Carlsbad. Carlsbad provided Billing, IT support, and staffing for PIW. Because of this, the other members asked Carlsbad to withdraw. Management has etermined that billing erors were possible due to programming errors which may be a ‘material Liability in excess of 100k. List of Key Documentation Reviewed “DocunentSource “Year (if applicable) “Aiidied Financial Statements ——=SCSC~*~S~S~ST OT _Form990 (Nonprofit fing) 201 eres CONFIDENTIAL age 68e fil tic const Ste of New Mexio Humae Saves Boprinent Behavioral Hela Provider Ads rl Rept BataceShet Aste Cos & cash equivalents Cont lig sv net of alowanse Progra cf eupmet Less scared deprecnion Prpidepenses Sofware erse Lesacunultelamoriation “Tota Asst bites ‘Aconzs Payaie re “Tota Libtie and Nt Asst a1 12667200 2333200 78800) 431000 stiss00 (1798500) snes 640800 8.00 56752500 s73933.00 Page 17anil FUMRIC CONSULTING Se New Meza Human Seve Deparment ‘eta! Heh Provider Ate i Repo Income Statement Revenue Govemmena exchange conets Medd fe Other serie ees ‘Conbuions, inking Renal income Oberincone “ota Revenues nd Soport expenses Progam services ‘Managemen & generat “Tota Expenses Change in Net Ass Net Assets benning of ear a 7309600 7479.00 ‘6apr00 37650000 993600 "20.00 13952800 as3,778.0 narana0e naisce 950800 CONADENTIAL Page 70e fh oo PUM COREL ia Report PATHWAYS BEHAVIORAL HEALTH PROVIDER AUDIT ‘Case File Audit Dates of Onate Review Fain Main Polat of Contact at Facil Exirapolated Dat of Service Overpayments Longitudinal Overpayments $85,521 “Total Overpayments $H194.256, ‘Scorecard results areas fllows: [ENERO Hare ea Tee Ce et ‘This scorecard resst translates to the following Risk Tier: 3 Significant findings, including ‘© Provide trainings and oli significant quality of ear findings. assistance as needed. Potentially embed clinical management improve processes. “See Page 7 caleho nih Pr Se PUI CONGUE: Final Repo ior Provider Overview Pathways ne, Mental Health Services s located inthe Albuquerque metropolitan area; it has two. Locations in'Bernalillo County. Within these locations, Pathways delivers behavioral health services including counseling and psychotherapy services for individuals, families or groups, psychiatric mediation prescription services, medication support services, comprehensive ‘communiy support services, psycho-social rehabilitation groups, and ersis services for adults. [PCG was tasked with reviewing several of these programs for compliance with New Mexico ai enue anil ll Payer ‘Claims Paid FYIZ ‘Claims Pad Ait Pevod BHD 316780 Tae creo ° ° Media FFS ‘581 18983) Meliss CO 1.935.208 6033521 nwo o ° over ° ° Grand Ti 2297189 763308 were there, wha to answering he: questions. + POG received their first ease file within 1S minutes and reviewed the fle with I WRI (0 ensure all requested documentation was present. The fle was provided in physical format and was supplemented with addtional requested documents within 30 I receipt ofthe fl. minutes ofthe ‘CONFIDENTIAL Pagee fil a runic CONS, nt Repo ‘+ Following a 3 hour wait for additional documentation, PCG epprosched I to request addtional documentation. MINN informed PCG that she was working on athering documentation but would not have any addtional documentation until the following day. + On Thunelay, Fehory 2Rth, PCG sented until 3 pm and had yet to receive any ‘ditional documentation, despite several requests. PCG approached III and the ior Patsy tears Builders, ad rensered their nesd to see documentation. A that point IN informed PCG that it would be 10 business days before we would be able to receive any supporting documentation for the requested claims. PCG's audit team lead was told that we would need to speak to their CEO if wanted documents soone than that. PCG's aut lead informed the MM that PCG would be contacting the State and Pathways’ CEO. PCG's team has left the provider site forthe dy. + PCG's audit team lead reported a Triguer Event (W2 - “After Entrance Conference, decline participation" othe PCG project manager, who then reported this to the state a 5:33 pm fon the 28th, + On the morning of Friday, March Ist, the PCG audit team lead who was onsite at TeamBuilders spoke with thei IE, wino indicated that there was 10 reason for PCG to have to wait 10 days to receive the requested documentation. ‘+ Shortly thereafter PCG's audit team lead at Pathways received a call from, wo ‘was very apologetic and sai that it was not ther intention to keep things from PCG but that “things were a mess” at Pathways and that she was trying to make sure she ean find ‘everything that was requested. © ACI] am on the Ist, PCG submitted another HSD keter 1 i sd “which required them to begin turning over documentation by | pm that day. ‘+ By [2:45 pm, PCG had received an additonal 3 files electronically and was promised st least 20 more by the end ofthe dy. ‘+ On the afternoon of Friday, Merch Ist, PCG met withthe Pathways biling manager who walked PCG through the adjudication of clinical notes sith billing outputs Later that ‘aftermoon, PCG met with the Pathways HR manager who updated PCG on the status of pulling staf records and walked PCG through the process of pulling each record from their system. CONFIDENTIAN Pageee min catanaetoeet rut Cops nl Rept © On Monday, March 40, PCC, oe: wits od MME 0 review their billing and clinical systems, including inputs, ouputs and audit veils ‘+ By Monday, Merch | th, Pathways had provided the rest ofthe request documentation Jina nea, well-organized electronic format ‘+ Clineat Reviewers noted the following generlfindings fo Safety Assessments were frequently missing for consumers who were assessed to have current or past suicidal ideations (SI, homicidal ideations (HI), self harm or domestic violence issues ‘© Comprehensive Clinical Asessments were not always provided to determine/support ‘medical necesiy forthe billed service or the provided assessments were incomplete of eitical information forthe date of Service under review. (© ‘Treatment plans were missing, not uptodate, and/or not ndviualied per consume. (© Progress Notes/Recipent Documents were missing, incomplete, and insufficient of necessary information. ‘Random Date of Service Clan Review PCG reviewed one hundred and fy (150) random date of service eliims for July 1, 2009" through January 3, 2013. Below is a table showing the relevant programs that were included in CG's random audit sample and the resulting findings: Pred pram Deion Cine Chime CARY Ems Cm ried tered rated mi aa as ioe Oupiins8S0nimes tO ass sei Fay Theme 1 88 aw se Falher 1a sa conte er ‘CONFIDENTIAL Papeat renews mill e Haman Serve Depart ‘etait Heth Provider Aue UIC CONSLING Fl Repo 31002) Maia Managemen 2 aan we Ca ‘Mena Heath Aseanent 2 mo ° 00% I [RN Mediation Monorag, oom HIS HO,HN HM—Cess 43 awa | No17) Pretest Rehabs 29 Im Grand aaa 10 89543 853% Specific Random Sample Review Findings For each program reviewed, PCG identified the level of compliance and any specific areas of concem, Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the elsim was found to be out of compliance, and the area(s) of concern PCG e denied CONFIDENTIAL Page@ pu tha @ -wuaaunoo “RL apnea oy 0} Supiowe poequapao ou Tv N | w Ww seg | weg eg sed SHOR a a aT eeeesarmm scone | | w | we edn || ee uct I “ana i | ataccrenom mmm | wow | ow fms | w | ve | ome | ome | oes sine ww we | es |e soa sr wean ep eng BN “erurerm my niappimerm tom | Wh = [= | 0 TEE eration] ws wma fm | me si — ey =| [ms aH = a tren taconite | wi es | omy | a ea |e tc ningan ua open enter mertirea eaten ent | mf me | me (ee EE ETE A wi | ome | ome se _soumourueumsesemeoiagueyyeeaae, | | i wi tn cge pep es emp ep pe Piorenrescentenorrmarersfesed ey wee | omy | as sone‘AWuNaatsNOD "Bis 0g Ba THRU, RD pera UDA Up $026.0) 260 eu we pes Lebeau SOG | _syapu wap pe URI eu op SOg Su) 364 | ‘wap psa uavtasecp G08 902 AL PPE ‘iumdnu sea $00 say hap pet "avs ¢09 #4016 LW pes ee OU ‘Soa 0 94 ep FE Ls sep SOO | 2,904 94 Wo Pg UE 9 GO BA 4 | ow ws wi ms ea | cd ‘ave pon wn poy we BUREN EHH N LoS sie “Wop 6 ov OMEN PAM PELTON ei Seo Say sas a Be SE raped sna tines pepe a a 1004 oe eed Sess wousona eu ten rier ssi ‘sons pms aj 0 eno Busey a 59 hu users ansg "waeprozena | Sepmane epsom 5 NN uae say ewan Bus mes BOL a rs “ei epva waa po eee I ee 8sus tea “wep | oUDUNS BIE @ ‘awunsa1sNoo airman a Sipe ean ARB ae eu sco 150 FD eS ses re rb NSO I AD Se | ‘ner oan sg used ups s/s|s|s|s/s zg es we a es stomeasy sviLNuuaNo meoeonmanhmniucneamusoenenao | Ww | wm |W ee | ice Babee am aa whom | ow we] oes | sea | seg | ses sic wel} ow | ow [see | ow | ee | aa | sey | ong si we] ow | ow foes | ow | ome oma | mee | og sows wim [ow [om ow | me | oe | oy | oo 0H wlio [ow [oe | ow | oe |e | me | oe sion wiw fw lw iw] w fw] ow ms soe wilwfwlwlw]w lw [ow a 00 wim | ow ws | oes | sea | sey 00% wi ow [ow wilw low ws si ‘wepraniuoeauene ete | wv | ow | wi wiflw | ow es S10 pareeaae basen wm ae wiow | ow we [se | ea | se so@ e e as [ enaeaosten| ww | “[»[~[™ [ae | ‘vepsaojsvouroonetessn | ww | wn | vN [ow [ow [| ow ws |i 51004 onmenaereon| wm | mw [wi mw) «| ww | [ile = as Se a EE ee nen | W | Ww ™ wow es seg | seg sed ‘shocH | scan nung neste nes | too ne na nc wonanaamnen| wf wfwiwiw|w|w|w |= se LL csmuapen buss eum cuvnsceupooomer | | mw | WN | ms) ww | sea | es | see a ‘10a whem fmt ft fel | mw ae wha fw) taf | | ow | mw sone ~[ ~ f=] ~ | es ww =~ f= [=~ | vo wf a wef] ome | om sie_pemeee yunp poeeauTR BoSHH ‘WuLNaGiaNGo EE cerstenas fla eeu i Le id (RE 9 ser2r00 tu ee... ‘ones Pauper uA, glelslsls slels/s ayiyile ene pics pogo “ap ou zg s i s|sls|s s|s|s|s flaleye sine)ave at nanaainos A wl w [wlll [~~ le fl a ri «| rl nod ‘sm w | ow we [| mw fm | om | om om w | sta = am w | se | = sion we | wf om | es | me |e] sioa4 ws mw es seg) wey seg ‘SLOCH | ee sae miwl~w[~w[ =~ | ow fo | som, es ww stg seed seed stg ‘S00 | ewe | el [fea | ema [= sim [fw [ome [ome | om [om 504‘WUNaaLANoD ‘poimevsmowis] w | mw | w | se | sma] ema | ema | om ‘vousiese sup pin tussn| ww | ww | we | sa | ea | oy | omg | emg wow | w | see | se | ome | oma | omytii | T ‘State of New Mexico il ill aes a ‘Sampling Definition: Sampling is a salsa! technique designed to produce a subset of clemenis drawn frm » population, which represents the charsteristies ofthat population. The ‘goal of ssimpling is to determine the qualities of the popuhtion without examining all the lemens in that population, Random selection ofclims is necessary inorder to produce a valid sample In random sample, claims are selected from a population in such a way that the sample is unbiased and closely reflects the characteristics ofthe population ‘Sampling Frame Size: Tol numberof claims fom universe of claims from which the sample was selected, ‘Sampling Unit: The entre claim amount ‘Time Period: 71/2009 1/31/2013, 150 claims. ‘Sample Size: Sample size is Extrapolation: The overpayment was identified using the lower bound of the 90% confidence imteeval Pathways ‘Sample Size 150) “Total Paid for Sample $8,525 ‘Sampling Frame Size 31,75 Number of Sample Cains with Overpayments 5 ‘Teattive Overpayment Using Lower Bound of the 90% aE Confdence terval a Longitudinal File Review OG selected between one and five of high risk procedure codes at each reviewed provider and ‘then selected the ive recipients who accounted for the highest dollar billing associated with each ‘selected procedure code. PCG then performed an administrative and clinical review of 100 percent of the clans associated with each selected procedure code and recipiest which were paid RENTAL Peeae tae of ico e fin vata uC CONN Fal Repo ‘daring calendar year 2012, Below is table sh CG's longitudinal fle review and there Provider Credential! Review For all random date of service claims and longitudinal files reviewed, PCG requested provider credential information for esch ofthe clinicians or other sta that had rendered the service. The table below shows the number of staff reviewed by provider ype: ‘CONFIDENTIALa= ‘Sue of New Mexico Tail | saline URC SNS ING rl Report TT/Billing System Audit System Overview Pata ans Et Perio at leone esth Record and Patina as thi iling ton, for their ‘They interface with the Optum portal to submit their bill for processing Wsent The duc at alway spans ect she Bah E Percoma Praca fare supported by their respective vendors at Pathways, SNM coordinates system administration El Perico is «program management system designed and developed by ECS, © software development company. The system is hosted and maintained at a data center managed by ‘Synergtic Systems Management. They are responsible for system backups and system uptime. billing syste is used by less than 10 providers inthe NM area. The product is ime by the creator ofthe Practma billing system. Pactima has basi checks for coding inconsistencies. It also is able to generate and audit trail. However i is rotted wo the ‘Optum Netwerkes portal whichis a common theme at all providers audited. There is a handotT between the intake, cligbiliy, EHR, billing system, and Optum. At any one ofthese points cerots could be introduce! even with the human double checking processes that Pathways has instituted, “The systems at Pathways are not well integrated which increases potential for data entry errors ‘between the data intake stem and the biling system. ake to billing was dserbed to be te following: 1). Data intake information and progress noes are entered ino the El Perico system. 2) Aer the progres notes are approved they are printed out and scanned into Intact, a document managenent system. 3) After seanning the printed data fom El Prico is used to enter the information necessary for bill ty sytem) to veri eligibility. 5) Practima interfaces with Optima Netwerkes to submit the requests for payments using the 897° forma, CONFIDENTIAL rae 186uc cons Final Repo a ‘Stale of New Mexico min vaulters Pathways has fully documented tsining system forall levels of staf and standard treatment paths thatthe clinicians will fice. At every step ofthe intake thru to the billing process, every step is double checked for accuracy. IT Contacts and roles 2 of Duties able to st login privileges for staff member to restrict access to tents information. She also is the manager who is able to set login privileges for staf ‘members to appropriately restrict acess to pats ofthe Practima system. Strengths and Weaknesses ‘Strongths: ‘© Have an EHR system that they use to record and track clinical records, ‘+ Have extensive training for every type of employee and diagnosis. Have inital training and training updates. + Each step ofthe billing process ffom intake to submission is double checked by at east ‘one other person ‘+ Have a disaster tecovery plan, ‘+ Have strong eligibility checking process, taining and system, ‘+ Have strongly documented intake process for new patients ‘Have strongly documented process for submiting billing cleims in batch process on regular basis to evaid duplicate billing. ‘+ Have an intemal audit person who monitors billing trends by region, diagnosis and providers to identify ineFciences or outliers that could be fraudulent ‘Weaknesses ‘+The point ofenty tothe claims payment system provides the ability t» change any billing from what the clinician entered, Both the data inake and billing systems log database and application information. But ‘due tothe amount of transactional information inthe logs it might ke difficult to find @ singular log entry responsible fora questionable transaction, ToNADETAL suenuenranaar Page 57aman Services Depetent ‘hail MelhPovider Ae a min Sha rune cong ING nl Repos ‘+ There is no direct connection between the EHR system and the bi could lead to human error in transribing. ‘+ Did not have 2 thorough termination plan for employees and their computer system access privileges “+ There is no complete audit unl of the entre clinical and billing transaction that is {guaranteed to correspond to what is billed to Medicaid ing system which Recommendations ‘+ Should develop appropriate accounting controls for charge ertry/iling in Optum Portal “CRFDENTAT Page‘Ste of New Mesa fil volta saton aT eae Enterprise Audit Provider Specific Methocology PCG utilized a consistent, systematic approach 10 conducting the enterprise aut of Pathways, Ine, PCG began by locating Pathways’ legal entity, its officers, and organizets. PCG ako reviewed initial founding and leadership information on Pathways, CG located and reviewed Pathways" audited financial statements and tax data, PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for other entities owned by key employees and contractors. PCG located related parties and ‘analyzed both the parties and te relationships, reviewing for potential conflicts of interes POG assembled the Financial data and analyzed it looking at key ratios, trends, and tracking variances. PCG tracked the organization's addresses and reviewed ownership of property online ‘or through the county assesors office, Finally. PCG performed media and cour record searches ‘on the organization or related individuals ‘This provider had a multi-year connection with Teambuilders Counseling Services Ina complex and evolving relationship, Fathways, Inc, is now controlled by Teambuilders. PCG simultaneously compared reporting from both enti Key Seat ‘Nancy’ Colella President Pino Treasurer Debbie Dziak Director Tey. ‘Schick Soathwiok ‘Consumer Rep Reedy Consumer Rep Donald ‘Naranjo Exee Director Campos Board member Freedle PresidenuCEOfil ura Cons Ste New Meio aan Service Dearne BetaviaralHeath Provider Aue Fl Reps During FY 2011, TeamBuilders Counseling Pathways payable over 3 years at 5% interest In FY 2012, his loan changed, beeing i Services provided an unsecured mortgage to or credit secured by the organization's asets. A second line of credit was established for $80,000, TeamBuilers officers. Summary of Findi s and Recommendations is also sccuted by the organization's assets. During FYI2, Pathways paid $87,000 to In FYI2, Pathways paid TeamBuilders officers as fellows: ‘Shannon Freee, CEO ~$29,207 + Lorraine Freed, CCO $14,844 4 Ben Luces, CFO -$13,182 + Sun Vega, COO -$24,157 ‘These officers should be evaluated for conflict of interest, inurement, excess benefit (or private benefit based upon these transactions. These individuals shouldbe evaluated to determine i they are disqualified persons ‘At 63072012, Pathways contracted with @ ‘Texas-based audit firm, Salmon, Sims for their audited financial statements and with a Kerville, TX firm (where TeamBuilders’ (CEO's brother i a partner for preparation of| [the ormanization’s tax returns. ‘These ‘accounting firms should be evaluated for private benefit. "AI 6/30/12, the loan balance t TeamBuilders was sted at $290,000. Involces from “Teambuildrs were listed st $185,000. "These transactions to and from Teambullders should be evalunted for confi of erent, Jnarement, excess benefit or private benefit List of Key Documentation Reviewed Document Source “Audited Financial Statements Form990 (Nonprofit ing) ihidgary cota ‘CONFIDENTIAL ‘Year (applicable) DORIS DIOE oir Page 8e inn ‘Sue ofNew Mexico oman Services Deine Beta! Heh Provider hate ruatic Cosson inl Reset ace Set 2 Er au aan Cah ches $ msuso $ smamo —§ iatatese spare ‘ean rae 5 raigmm $i $ID sO reid eepenes 5 zmo0 $34 welsm § S380 ranean bp om Ss susam 5 6LAskan ae opty ioe cast $2378.00, 5 Ue.i00 § aes lures sue 5 aus 5 Seis areca 5 lesan Tet et s26u.000 s2snissi0 ahaa ‘Ass Paate © ummm sacs § wane § n4an300 ‘ese 5 texto § Gum $$ tain Nessa cre poi S tigsoo $num S$ Trams h46e385a0 Nosy hssewnniprion «$1. 7URO «$A Se ‘ese en cnaion s msm s ‘scrap swore se Acc py wes sume s ouspytle nese oes 5 ioissssco nse ol ay 5 2moma0 Tom ite Stamamon — $28132160) $2216.00 sass Net An S aassrrae $c § mzIM —s 1asro0 ‘oalLiehiesoodNetAses ——-$361300900 SI INERE —S2aMtNe —s2azaR0 CONFIDENTIAL Paesaii iad il Il ees @ ae a0 a an Schncndihroqpanenoone «$a $$ SEND sae eal appert So umsee sams 5 asus $a tps sd S$ uonosme $u$ Lassen $t4oH000 eg ped ssa $a sean 5 wsasen To Eee 5 ronmee sums samme s sasuaee © amr iant eat 5 naman snes § aay § una ining sr re ‘CONFIDENTIAL PageService Organization for Youth Inc, ga0 B= EEE eTa= nc of fin foe ail Ss SERVICE ORGANIZATION FOR YOUTH BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit ‘Dates Onsite Review Mach 13 19,2013 ‘Main Font of Contact a Facility rtrapalated ate of Rervce Overpayments STS ‘Actual Longitudinal Overpayment Si4018 “Total Overpayments $2174 ‘Scorecard results are as follows: ORI MEAS Ss ini ¢ > ori “This scorecard result translate othe following Risk Tet: 2 Significant volume of findings that «Provide trainings and clinical inlude missing documents sistance as needed. ‘Potentially embed clnial management to improve processes, “connpetial ‘ Pagetfi State of New Mexico Till canner a i Provider Overview ‘Service Organization for Youth provides behavioral health services in Raton, New Mexico ‘Within these locations, Service Organization for yout, delivers behavioral heath services including counseling therapy for groups, individuals and families, prevention services, family services (CYFDprotstion services referral required), Juvenile commanity correction services (C¥FDIjvenile justice referral required), treatment services for youth and thelr families) and the summer food program for youth employment. PCG was tasked with reviewing several ofthese programs for compliance with New Mexico regulations Payer ‘S$ Chains Pata FID ‘5 Clans Pal Auait Period ‘BHSD Bai 100,201 cyrD 1603 299,066 Medicaid FFS 5601 is Medica! CO 209.46 536,283 iweD) ° ° Other ° ° 9807 (Gras Tota ‘Audit Team Observations + An cotmnce conference wae held ith TT wi minutes ofthe audit team's arial onsite. ‘+ SOY isin the process of merging with Easter Seals El Mirador. Once that transaction is ‘complete, certain Funtions willbe shared among the two organizations and Easter Seals ‘ill provide Ql, personnel and most other types of support. Easter Seals will also actos the main billing provider, using their own billing management system, through which SOY would license thei program and loa billing. Since SOY does not use EHR, all clinical files were provided in paper format. The files ‘were well organized, All files were provided by KINI with assistance from his nial snd anitratve sta, CONFIDENTIAL. Paselitfil Sree e inl outer punk Const Nc ial Rep + III proves har copy originals ftom the files that were subsequently scanned ‘by PCG onst staff. The files were well organize. + Clinical Reviewers noted the following general Findings: 1© Comprehensive Clinical Assessments were not always provided wo etermine/suppor medical necessity for the billed service of the provided assessments were incomplete of citcal information for the-dteof service under (© Treatment plans were missing, not up to date, andlor not individualized per ‘©. Progress Notes/Resipient Documents were missing incomplete, and insufficient of necessary information. Random Date of Service Claim Review CG teviewed one hundred and fy (150 random date of service claims for July 1, 2009 @ trough ana 31,2013. Below is table showing the relevant programs that wer inlded in CG's random adit sample andthe resulting findings: Poste ga Danie Chiat Sains sned_toered = 1 ‘ine Onpien—2ninns BE ee ee ee ee en eee ert 1 s ° ° 0.0% ee ee ee Pn Tey «m8 90807 Family Therapy nse ° ° 00% ony SnmtnPocieny yg isc Ts aR SAM “coNRIBENTA aeraB= ae Sate ofhew Mexico ieee ir iI ee a = eo “Ho031 Moti Health Assessment 4 20 1 1 15.0% esa eects tie ee Se ers ners Sore ST aut can aS Specific Random Sample Review Findings For each program reviewed, PCG identified the level of compliance and any specific areas of concern. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found t be out of compliance, and the area(s) of concern PCG ides ‘CONFIDENTIAL Pose 0tested “VUNaIENOD mpm tow foes | om | ow fom | om | ow ‘ois wlio {ow ] mim | ow fw | w ao we fim [ow [oe [ow [ome | oe | me | oe Sie we} om | ow foes | mw | os | os | os | ote sto wil fw lela low fw | we sg ia ie ofNew Mexio mill — ‘Sampling Definition: Sampling isa satstical technique designed to produce a subset of elements drawn ftom a population, which represents the characteristics ofthat population. The goal of sampling isto determine the qualities ofthe population without examining al the clements in that population. Random selection of claims is necessary inorder to produce a valid sample. In random sample claims are selected from «population in such a way tht the sample {is unbiased and closely reflects the characteristics ofthe population. ‘Sampling Frame Size: Total number of claims from univers of claims from which the sample was selected, Sampling Unit: The entire elsim amount. ‘Time Period: 71/2009 1/31/2013, ‘Sample Size: Sample sie is 150 claims. Extrapolation: The overpayment was identified using the lower bound of the 90% confidence imterval, ‘Service Organization for Youth ‘Sample Ste 5) ‘ota Paid for Sample stags Sampling frame Sse nas [Namberof Sample Cais with Overpayments s ‘Tesiative Overpayment Ung Lower Bound ofthe 90% ae ConfdenceIatera Longitudinal File Review CG selected between one and five of high risk procedure codes at each reviewed provide and then selected the ive reiplnts who accounted fo the highest dll billing associated with each selevied procedure code. PCG thew pefoniied an edinisuative aid clinical veview of 100° percent ofthe cleims associated with each selected procedure code and recipient which wer pid CONFIDENTIALuc CONSULT during calender year 2012. Below isa table showing the relevant programs that were included in CG's longi ile revew and te eating Tings: rex Prem FafGeen Ful SCuims came S00 ca SL Bin nent ees Aces "Soa" he" Family SoH82 Subanon s mao st 240 293% Provider Credential Review For all random date of service claims and longitudinal files reviewed, PCG requested provider credential information foreach ofthe clinicians or other staf that had rendered the service The table below shows the number of staff reviewed by provider type: FovierType a Therapist 7 ‘CONFIDENTIAL| i ‘State of New Mexico All vasa tat a he IT/Billing Systems Audit System Overview ‘SOY usts Medisof software for tei billing, Mediso is a3" party, cloud based billing system ‘based on Microsoft technology. Mediso uses Optum Netwerkes ACH and Optum Portal to submitter bill for procesing and payment. All PCs are encrypted Bil process Data intke forms are entered ito the MedisoR system and electronically scanned and stored on a secure file server. Raton sends data intake forms ad progress notes Taos office fr billing “Taos ofce receives forms, scans paper documents and stores them on file server and then data is keyed into Medisoft. Raton uses an older secondary billing system fo manage adult sevice billing and will convert ove ll illing to Medisot later this year Fee rates come from Optum andthe State and are hand keyed into the system. Raton is curently sending Outpatient Service billing to the Taos office and is processing Foster ‘Care hose serves through the ol billing system, IT Contacts Application Controls - System Walkthrough {ll data intake information collected on saper and encounter data is entered into the Medison 3" party system, The paper forms are keyedin by a small numberof staf. The claims are billed on 2 ‘monthly basis. ‘The El Mirador office isthe central acccuntng office for both Raton and Taos. After claims are submitted by Taos end Raton a spreadsheet oftheir billings are sent (A ac MII 0: review. Both of them analyze the billings and review the data for increases or decreases. Pose @fini ee: uae CONSUL, "al Repo IT Strengths and Weaknesses Strengths: ‘+The Medisoft software application is provided by a division of Mckesson, a $123 billion olla health company. ‘+The Medisoft software is a cloud based, practice management software application that is secure and backed up on a regular bass ‘+ Medisoft ser names and passwords are not shared and are distributed to individual users. + Claims and remittances are sent and received electronically through Networks ACG clearing house ‘+ Thesystem has reports to reconcile billings and remitances. + None ofthe staff have acess to the billing system source code. ‘Formal raining to use the system ie provided to the uses, * Visual inspection of latest rates and corresponding procedure codes that were in the system was dane by examining application sereens and ihe data was core. ‘Weaknesses: ‘The weaknesses identified below are common among all the providers we audited especially the three groups that are orgenized under El Mirador because they all use the same system and ‘owned and managed by the same central corporation; El Mirador, Taos and Raton, ‘Application controls may be compromised bythe following application risks: ‘All data forms are keyed into the application by few individu ‘©. Despite the application's data entry edits there is opportunity for data entry error. ‘There should be a periodic udit of the sored electronic form and the corresponding data that is stored online (¢. compare # of units and procedures) to se if ifferences exist. + There is opportunity for clerical staff to create and manage fittous clients and providers, Independent audits ona periodic basis are needed to verify both the provider and patent and the patient's condition exists Recommendations Develop a procedure to verily that billing da in 837s and remittance data in 8355 ‘balance out using the Meisof accountng repr orather available reports. CONFIDENTIAL Page 25a a-s ll Site of ew Mexico fl I oa ae et eee a ‘+ Develop a procedure to confirm that billings and remitances match to progress notes and billing data in the Medison syste. ‘+ Create a process to verify tht patient treatment documentation stored as an image onthe image server matches what is inthe Medisoft database on a monthly or quarterly basis 0 prevent data entry mistakes. ‘CONFIDENTIAL Page 25‘ll Till Human Service Deport Beta Heath Provide ron pone Fit Report il I ‘State of New Mexico Enterprise Audit Provider Specific Methodology CG utilized a consisen, systematic approach to conducting the enterprise audit of Service Organization for Youth (SOY), PCG began by locating SOY’s legal entity, its officers, end ‘organizers. PCG also reviewed inital founding and leadership information on SOY. PCG located and reviewed SOY’s audited financial statements and tax data, PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for ‘other entities owned by key employees and contractors. PCG located related parties and analyzed both the parties and the relationships, reviewing for potential conflicts of interest. PCG assembled the financial data and analyzed it, looking at key ratios, trends, and tacking variances. PCG tracked the organization's addresses and reviewed ownership of property online or through the county asessor's office. Finally. PCG performed media and court record searches ‘onthe organization or rated individuals, Audit Observations Service Organization for Youth (SOY) is small on-proft urpuniation administering services to youth and their failies to provide crisis intervention, educational atistance, and placement ‘oreferal of youth who need alternative living erangements. Key Susi Karen Murray President Torta Encinas Vice President [Mak Bayliss Member ‘Suzanne Baze Secreta Treasurer Ferman’ Uilibaei Exceutve Diretor Serena Tannon Financial Manager Terry Baca Member ‘CoRFIDENTIALSie ofNew Meio Human Services Dearne ‘Behar Heath Povier Ate al Repo Tn 2010, SOY's auditor noted that there were problems with biling and colleting from OptumHealth and recommended more teaning for staf. ‘SOY is planning to merge with Easter Seals which will optimize administrative services and transfer biling responsibilities to Easter Seals. SOY's denials should be reviewed for List of Key Doe DocumentBouree — Vear “Audited Financial Statements 20102008 ‘Form 990 (Nonprofi fling) 2011, 2010, 209 “Third party contracts, OER he a ‘CONFIDENTIAL FwHuman Services Deane Beton! Heh Provider Nate rum consutie nal Report fill A Bac et mw i Ca ch sas + asec Recviie-pomeceancs state Pentre fawest pees 2anbn Leracomltdemeston 109500) Tea Ant senso sai ‘era 53st Rennes wing pale F138 Porte pate 3 ome Over wene 3 asia Nat + Gam eo 3 see ong § enon Colne 3 ose Test is son ca 5 mano ‘Toul Libies and Net Asses $185,369.00 SC 777 SS BESS GESTS GE TSEEGESRTSIESRETSESREESESSIETE “7ari ml Income Statens Baia ‘te contains inked Speci events ere et tet reese from ett “Tote Revenue and Support Expenses Communi Based Services Faelity Program Tal Cmmaniy Approach Time Lites Reaietion Steer Food Prose Juve Commit Conetons Mise Family Preservation Juvenile Drug Cour “Tocco Ute Prevention ter Fung Managemen gee Change in Net Asses (unrest) {Change in Net Ass emp esti) ‘Tota change in Net Assets Ne ane bepalng oe eloped adjtments Net Assets endo year Ste of New Meco aman Sewzes Deparment ‘Behav Heh Provider Ai nl Rept 209 5000 7549.00 900 1233600 seassico ins000 assto0 5s 1H9.0 Ss 600.00 5 Bae00 5 nooo, 5 mansa0 CONFIDENTIAL Pee 0Southern New Mexico Human Development a=Human Servis Deparine ‘betavnal Heath Provider Ate FURACCONSULIING "a ope Ba mail —— SOUTHERN NEW MEXICO HUMAN DEVELOPMENT BEHAVIORAL HEALTH PROVIDER AUDIT Case File Audit Dates of Onsite Review ‘acch 6-14 2015 ‘Main Pont of Contact at Facility Extrapolated Date of Service Overpayments ‘Actual Langludina! Overpayments “Total Overpaym SLE 379 ‘Scoresard results are as follows; 63% 65% — ——_—_—_—_—_—

=)= |= fille wlelalwlele |=) =| = | wiwlelwiwle |=) =) = [lew a3hetetee tee be | wl ow Ww ew | ow] ors wa] seg eg ‘shozu | penance | a |_swousion sxouyorno ai an i0N'300 _ iif a =estes See i ‘TWUNGGLNODfin —— runic cons ING: "na Repo Sampling Definition: Sampling is a statistical technique designed to produce a subset of elements drawn from a population, which represents the characteristics ofthat population, The goal of sumpling is to determine the qualities of the population without examining all the elements In hat population, Random selection of claims is necessary in ordet to produce a valid sample. In random sample, claims are selected from a population in such a way tat the sample {is unbiased and closely efets the characteristics ofthe population ‘Sampling Frame Size: Total numberof claims from universe of claims from which the sample was selected. ‘Sampling Unit: The enire claim amount, “Time Period: 7/1/2009 ~ 1/31/2013, ‘Sample Size: Sample sive is 147 claims Extrapolation: The overpayment was idemified using the lower bound of the 90% confidence “TeamBuildes 7 ie sis366 Tia [Number of Sample Claims with Overpayments au ‘Tentative Overpayment Ulag Lower Bound o ie 90% Sea Confdeace Interval Longitudinal File Review PCG selected between one end five of high risk procedure codes at each reviewed provider and then selected the five recipients who accounted for the highest dollar billing assolated with ech Selected procedure code. PCG then performed an administrative and clinical review of 100° percent of the claims associated with each selected procedure code and recipient which were paid CONDENTALa ic fill ener FUNC Cons al Rep ‘during calendar year 2012. Below is a table showing the relevant programs that wee included in CG's longitudinal fle review ant the resulting findings: Proc Program —#ofCater Claims $Caims Claims SY*M° 94 Claims ‘Code Description Reviewed Reviewed Reviewed Failed Fealed “able below showsthe number of staf? reviewed by provider type: Trader Tipe Reviewed ‘CONFIDENTIAL Page a5ii coalesce oie Tl SaiofNew Nexis TT/Billing Systems Audit System Overview ‘TeamBuilders uses EMR Bear as their Electronic Health Record and Practima as ther billing system, They interface with Optum Netwerkes to submit thie bills for processing and payment. ‘The IT department at TeamBuilders supports 18 different ses. There is one person who i in charge ofthe EMR Bear implementation and he is an expert who handles upgrades and usage a5, his full time job, There is one person who isin charge ofthe Practima billing system and hares ‘upgrades and issues as his fll time job [EMR Bear isa product that was designed by & Behavioral Heath profesional. It does not hve 8 very larg footprint and it is very popular armong te staff members of TeamBuildes. They are able to efficiently use it to creat their case files for patient treatment. TeamBuilders spent a 2 year IT investment in another product that tured out to not be reliable and interfered with safT ‘members performing their duties of recording patient treatment. TeamBuilders concluded that it ‘was better to switch back to EMR Bear which does not do everything they wish it di, but i in their opinion, reliable ‘The Practma billing system is sed by less than 10 providers inthe NM area. The produc is supported full time by the creator ofthe Practima billing system. Practima has basic checks for coding inconsistencies It also is able to generate and audit tral. However it i not tied tothe ‘Optum Netwerkes portal which i «common theme a all providers audited. Ther is a handofT between the intake, eligibility, EHR, billing system, and Optum. At any one of these pcits ‘erors could be introduced even with the human double checking processes that TeamBuilders has instituted. ‘TeamBuilders also hes an intake and eligibility system. They have a fully documented trasing system for all levels of staff and standard treatment paths that the clinicians will fae. At every sep of the intake the tothe Billing process, every step is double checked for accuracy. FT Contacts and roles Corea reeceae Su of New Metco am | Human Servis Deparment ume gag ial Repor Application Controls ~System Walkthrough: Administration and Segregation of Datioe ‘The EHR manage is able to set login prlvileges for staff members o restrict acess to paien's information. The IT billing manager is able to set login privileges for stafT members 10 appropriately restrictacces to pars ofthe Practima system, Strengths and Weaknesses Strengths: ‘+ EHR system hat they use to record and track eine records ‘+ Provide extersivewaining for every typeof employee and diagnosis. Have inal waning. and taining updates. Each step of the billing process fom intake to submission is double checked Disaster recovery plan in place Strong eligibility checking proces, traning and system ‘Strongly docemented intake process for new patents ‘Strongly docamented process for submitting billing claims in batch process on regular basis to avoie duplicate bil ‘+ TeamBuilders has invested in EHER systems and pu out an RFP forbid a couple of years ago. TeamBuilders appears to keep abreast of new developments inthe BHR space. ‘+ An internal cudit person monitors billing trends by region, diagnosis and providers to idemify inefficiencies or outliers that could be feaudulent. ‘Weaknesses: ‘+The point of entry to Optum Netwerkes provides the a what the clinician entered ‘+ EMR Beat isnot configured to easily provide an audit tail ofthe events ofan enco.nter ‘© There is no direct connection between the EHR system and the biling system whic could lead to human ert in transeibing Did not have a thorough termination plan for employees and their computer system cess privileges ‘+ There is no complete audit trail of the entre clinical and billing transaction tat i _uaranteed to correspond to what i billed to Medicaid iling rom to change any rTfil nen Setar! Heath Provider Aus rant Const a As Recommendations ‘Develop appropriate accounting controls for charye enyhilling in Optum Portal and Optum Netwerkes.Ste of New Meco Till iil Human ences Deen ‘Bebavr Heath Povier Au func Eon ial Repo Enterprise Audit Provider Specific Methodology In condectng the standard enterprise review of TeamBuilders Ceunseling Services (TB), an extraordinary rumber of unusual financial relationships and related party transactions were discovered Accordingly, PCG researched the organizations finances a fr back as possible (to 2003), reviewed ownership of properties and researched «numberof imited lability companies ‘owning propetics that TB rents, Most ofthese companies are owned by TB executives and thelr families. PCG also looked at other non-profit providers that had linkages (0 TB and organizations associated with or compensating these executives, Finally, any financial tanssctons that appeared unusual were examined. For example, a construction contract with unusually beneficial terms to the contactor prompted contact with the local building department, through which PCG ‘was ble to trace the construction company back to an address in Texas owned by the TB CEO snd his brother Audit Observations ‘Teambuilders has an excessive number of related party transactions for a non-profit and a substantial portion ofthe organization's funds are being used to benefit the executive team, thelr families, or companies closely held by these sume partis. It unasul that so many ofthese relationships exit ina 01 (c) (3) organization, which is «special satus granted bythe IRS with ‘significant regulations to insure that these kinds of charities eam a public rust. In granting this special status, the IRS prohibits inurement; meaning that the assets or income of ‘non-profit organization cannot be used to benefit an individual who has a close relationship with the organization or is able to exercise control over the orgatizaton, This prohibition is found inthe language of Intemal Revenue Code $01 (c)(3) “A section 501(c)(3) organization must nt be organized ot operated forthe benefit of private interests, such as the creator or the creators fiily, shareholders of the organization, other designated individuals, or persons controled directly or indirectly by such private interests. No part ofthe net earnings ofa section $01(e)3) organization may nue to the benefit of any private shareholder or individual.” ‘CONFIDENTIAL Pageil fil oalttnaareeres: runic CONSUL Pal Report Key Statt im Thier Dietor Ennai Breen Director Chae Sandoval Dietor sob Caldwell Direior Shannon Freee President orine Frese Vice President Ben tes Son ees Willa Tohnson Tin Teneghan Finansial Relationships Plain View Properties, LLC | Limited liability corporation -] This company leases real exempt estate to TeamBuilders Full Gicie Holdings, LUC [Limited Tabiliy corporation ~| This company leases real exempt state to TeamBuilders ‘Yellow Brick Properies, LUC | Limited Tabiliy corporation =| This company leases real exempt estate to TeamBuilders ‘Oso Doso Properties, LLC | Limited Nablity corporation | This company leases real exempt estate to TeamBuilders Zia Behavioral Health Domestic Profesional | Providers of behavioral Relth Corporation services ‘Community Wellness Cenier | SOT(E)) is organization addresses challenges of unintended teen pregnancies in Taos County Partners in Wellness EoD) "This organization networks administrative and behavioral health services CONADENTIAL Page 280aa ‘State of New Mexico mil ll Haman Sevies Depart ‘hava Heath roi Ade ruwoconsu iN al Rep Pathways Youth & Fanily [S0/@0) ]"This omanization provides Servies, Texas social services for Texas children and Families Pathways ine, New Mexico | 50(0X) ‘This organizaton provides cage management, psyeho- social intervention, and ___| substance abuse counseling Habiliaive Homes, Texas | S0i(@)@) "This organization is held by Pathways, TX and provides rehabiltaive homes in Texas | Davidson, Freedle, ‘Domestic Professional Providers. of financial, Espeshover, & Overby, Corporation accountirg, and tax services Kerrie, Texas CONFDENTIAL Pretmates WuNaaianws ‘suomejar jag s890K9 Japun ,uosiod wy ouNG S/T] Tomedaig MEINuINa = 01 2] 2 ua tp 30} SoU eT ‘wonta0| sp 395 sodop Asnoes ut 6S « ‘wowsnond poyesea| ut 000'0ss ISHS 50 soa 5 28NYEIE 9 JO.%4001 © ‘200id uoponnsuoo xp BuLNp 59g ‘Sl2pMEWNDL. “L067 UH | 2 pur prove, juorppy ose Jo myo 205 | paume 29 prncus 577 ued pois 2 way uouised « ATP Ue JO TZor YBnouy oKNNENIOD nonn ooF'BOFES 1 showed 2504, yey pue OAD ,soplinquaeeL, q__pauno sajunduo> Aayge penny 04 pied 536807 a suoepuoumosoy pur sujputg jo Crewing onuanino3 nangoat ayunaaiasoo ‘suopepadar ysu29 sse0x9 s2pun vowed payenbs mm 1 pavenjer> 39 PINOY OTT seq young ateaud so/pur ‘yaoquy_Jo_Jxyue9 so} POIRNEAD 2q PINOYS SIDI suoqeyar wyou5q uosiod paynenbsip, 11 J) suWH9p ‘deg ok pe poi eH OHI, ‘ada ssrans ven ‘on aan 2“IWUuNaLENOD ‘asariuy Jo IyUo> 405 pawnyeAD 94 PINOYE si2INIO “suopejadou ysu39 owes 208 L107 01 2907 Woy SuBUIKEd 95027 ‘uedwo> 29 Jo 132100510 oq 6 past 51 03D “fued paras ese past,sreaies WuNaa1N0o suosiod payenbsip 10351341 wou Kaun 3 9 PIROYS SUOHVEZIUEELO 33410 "saplmgue2] Jo 994 8 03 uLUeS 24_pinous _swoau) pela! pue wopesuodwos mos 1 sump 01 ‘Wl OLAd Ur WETS J0 Uonesuadinon panioai paw 1H=D ssouyaq Ayumuniog Joy QgD se SONI96 seo] I + “089 219 J0 9019 pus Sosape xe sapuinguesy “212 “qpaa1y ‘Yorpiaea se supe aunes ay Kuediwop sexay.« ome ‘Sy a:AI2y, [uP uontiodso> sex2y © ‘1589 1M — ITT 20 Om Je sBBeuew se senses “Os Change in Ne Assets Famsiso — s aursn) —§ eas) Net Assets bxioning fear S34gas00 —s3smy7enn 3294490100 Net Asses endo yer saumrauie 5296499100 sromor4ee CONFIDENTIAL Fae 6Youth Development Inc. ae e co Baaae af New Menon e fm a usuC cons ma epee ‘YOUTH DEVELOPMENT INC. BEHAVIORAL HEALTH PROVIDER AUDIT (Case File Audi Dales of Oniie Review Fabry 27 ~Mach 52013 ‘Mata Polat of Contact at Facility ‘Extrapolated Date of Service Overpayments ‘Actual Longitudinal Overpayments “Total Overpayments $296,570, Scorecard results areas follows: ‘This scorecard result wansates tothe following Risk Tier: 3 Significant findings inclading 1+ Provide tininge and clinieal significant quality of care findings. assistance as needed, ‘+ Potentially embed clinical management to improve processes. e@ ‘Potential change in management. CONFIDENTces il ail etter fu oN Repo Provider Overview “Youth Development Ine has six locations in the Albuquerque metroplitan area. Within these ‘locations, Youth Development delivers behavioral health services including tutoring, afer~ ‘school activites, gang intervention, drop-out prevention, family counsdling services, emergency ‘teen sheter, youth sports, inteships, scholarships, parenting skills, leadership development, public housing assistance, community comcetions, GED studies, early childhood education via Head Surt centers, substance abuse and AIDS education and other services. PCG was tasked _with reviewing several of these programs for compliance with New Mesico regulations. Payer Claims Paid FYI2 ‘ Chain Paid Aust Period ‘iso am) a2 cyFD 4971 1,034,640 ‘ees FS a 3H Mediais MCO 523431 1049054 WED) ° a ‘ter 17988 758,08 Grand Tota 1011959 294506 Audit Team Observations + Antrance conference was el within two hour ofthe tan's aval oni as fie A as sina to serve ithe team’s pin of contact tthe se. Also ptiipatng nthe enrance conference was + Case files began to arrive within an hour of the conclusion ofthe entrance conference. “The majority of files were provided within two business days. A numberof files were Frovided later because they had to be retrieved from storage. Two case files could not be Ioeated, + allease files and supervision logs were provided in paper format and the PCG audit eam roanually pled the necestary documents from the case files. Personnel fles were rovided in electronic format. ENTIALSine of New Mexia iil aii Human Service Dotnet Behar Heth Provider Aa ume conga. ira Repo + Case files hada defined organizational format that was observed in the majority of case files reviewed ‘+ YDI sft was prompt in responding to audit team requests for clarification or additional information. ‘+ Clinical Reviewers noted the ellowing general Findings (© Comprehensive Clinical Assessments were not always provided to determine/support ‘medical necessity forthe billed service or the provided assessments were incomplete of eitical information far the date of service under review. © Treatment plans were missing, not up to date, and/or not individualized per consumer. (© Progress NotesRecipient Documents were missing, incomplete, and insufficient of necessary information. ‘Random Date of Service Claim Review PCG reviewed one hundred and fifty (180) random date of service claims for July 1, 2009 through January 31, 2013. Below ia table showing the relevant programs that were included in PC's random aut sample andthe resting findings: Froader eg erp Chime Caine Chis ms "Chim ewmed Reena ate ee i Aeon ee Ong 2020ninas $8 ee ee er sme Ovpnen1s¥0nimms tf oa (oS sme) Fam Thy ise oc tite ttt ane 989) Ox tiney i ee sas Wott Fn Csi) Bam 88 aww ical oberon sea 7 ee “CONDEimi Aik te ie—n ‘Setar! Heath Povier Nae ute CONSUL ial Repo HIS HO. HN HM —CCss utes SCC cat 10 sas 27982 180% Specific Random Sample Review Findings Fer each program reviewed, PCG identified the level of compliance and any specific areas of concer. Below is a table showing each of the non-compliant claims PCG validated, the reason(s) why the claim was found to be out of compliance, and the area(s) of concern PCG dented CONFIDENTIAL Peese ioe s 3 i g | E |8/ 8 i = yes @ @@ @ e meat ‘avuNaatsNoo sichereotea ‘AviuNaaLINOD ‘spun ag fap m psa on BI FSIET ONAN y | } | | {i | wlow | ow | om | we] om | me | om ms 51024) | mefow |e fom | ows | seg | omg | oe co | wefom | om | w foe | oe | mw | ome ‘i004 welow ow fom | ow | ome | oa | me |e | siozs wf ow fom fom | ow foe | oe | sey | omy smwow fom foe | ow fom | ea | meg | sg siscH | we) ow | ow |e | ow | ee | me | mee |e 34 we | ow {om foe | me | res | oa | sy | ae soca mow | ow | ome | ow | ome [om |e a sion wow | ow | ee | mw | oer | see | osey | ee 5004 | wiow low | wm | ow | wa | ee. sa oy 1034 Sopetes 0 no mip nase agen 0 HEN ‘pes este on1 910 vie sme eisreaieg ‘AWHINaGLENOD : z s z z 2 i =Ba fall aoa ruc ONIN inl Report Sampling Definition: Samaling is » statistical technique designed to produce a subset of rom 8 population, which represents the characteristics ofthat population. The {00 of sampling is to determine the qualities of the population without examining al he Clements in tat population. Random sleton of lis is necesayin ode o produce a valid sample, Ina random sample claims are selected from a population in sucha way tha he sample is unbiased and closely eles the characteristics of th population. ‘Sampling Frame Slze: Total number of claims from universe of claims from which the sample was selected, ‘Sampling Unit: The entre eam amount ‘Time Period: 7/1/2009 ~ 1/31/2013, ‘Sample Size: Sample size is 150 claims. Extrapolation: The overpayment was identified using the ower bound af the 90% confidence imerval, ‘Youth Derlpment ‘Sample sie 15 ‘otal Paid for Sample sis.o45 Sampling Frame Size 26383 [Number of ample Claims with Overpayments n ‘Teatative Overpayment slag Lower Bound f te 90% Confitene interval aa Longitudinal File Review CG selected between one and five of high rsk procedure codes at each reviewed provider and then selected the five resipents who accounted forthe highest dollar billing associated with each selected procedure code. PCG then performed an administrative end clinical review of 100 percent ofthe claims associated with each selected procedure code and recipient which were paid “CoNRDENTIAL PagesSie ofNew Metco @ Huma Senet Deprment Sekai Heat rover Ante il l Tl rl Repo uring calendar year 2012. Balow i a table showing the ralevant programe thet were included in ‘CG's longitudinal file review and the resulting Findings roc rogram af Cases #CInins Claims Cade Daeripton Reviewed Reviewed Review ome Ht ee 5 4386 Ho, tte we, 9% aois HOH s ne Grand Toa 1 30 ash a7 ease e@ Proviler Credential Revisw For all random date of service claims and longitudinal files reviewed, PCG requested provider credential information for exch ofthe clinicians or other sa that had rendered the service. The table below shows the numberof staff reviewed by provider type: “Provider Type Sree F keviewea ‘Community Sport Worker 7 ‘Therapist a Residential Worker 6 Intervention Specialist 1 Uskacwa/Oiher 6 Total Staff Reviemed 3 “CONTENT PaseTa a eis mill satan A aie in 78 1g Systems Audit ‘System Overview For most ofits billing, VDI uses 1 Perc, a clinical ad billing system that integrates intake, clinical noes and bilirg. While YDI does have « Mirosolnetworksytem, iris used only as File server and does no: contin ay billing or clinical information. All billing is performed on tree separate systems that process information in the cloud: “+ Elenco heir main bling system, Al iling that i biled hourly or forthe service is billed through El Prico. + Optum Neiwertes, online EDI clearinghouse. El Perico cretes the 837 and itis uploaded through Optum Netwerkes. ‘+ Optum Provider Poral~oneline portal is usd to bil services that are billed at ay rates ~ shatters. + MMIII coors that Optum Heath recommended El Perico to YDI. She cannot recall which staff member(s) made the recommendation, IT Contacts Application Controls - System Walkthrough Administration and Segregation of Duties User Roles ‘Agency Administrator Role: Can create new uers and setup new payers/insurane plans. ‘caNDENTIAL ag a e@ ‘i ‘State of New Merico fi! coalesce Me aie Billing Administrator Role; Can create new services and generat billing. aaa nical records of staf hat so, : ‘Community Suppor Workers (CSW) crvie Provider Role; All elniians who bill and are on the payroll have the Service Provider Role, which can add clinical serves to cients assigned to them. ‘Auditor Role: No staff t YDI curently have the Auditor Roe, IT Strengths and Weaknesses Strength ‘+ YDI's billing applications are in the cloud, which make for ease of use from any computer and uniformly enforced security pie. ‘+ Users donot share login accounts; new passwords are required every 90 days. ‘= Eachetinician enters her own charges. Weaknesses: Application controls may be compromised by the following application risks. ‘+The point of entry to the elaims payment system provides the ability to change any billing from what the clinician enered: (© InElPerico, the 837 can be changed when connected to Optum Netwerkes. The person uploading the 837 an make any changes to billing with no aut til ‘© In Optur Portal, the clinicians can repot a certain number of days, but both the source documents and what is entered in the portal ean be changed by staf? entering the information, Training done mostly onan adhoc basis. Without «formal taining and tacking system, uniform direction as to the use of he system eannot be guaranteed o tracked, ‘+ Disaster Recovery ~ El Perico demonstrated adequate disaster recovery plans through its application hosting sevice arrangement, but YDI presented no disaster recovery plans for all ofthe paper client records in its possession, ‘CONADENTIALfii ‘Stale of New Mexico Till wane Ei a ‘Recommendations ‘+ When and if financially feasible, migrate to Electronic Health Records to integrate the health record withthe billing sytem, to have tight controls between clinical and billing teil for any changes made to 837 files when they are uploaded to the clearinghouse. ‘+ Develop appropriate accounting controls for charge entryPilling in Optum Porta. ‘+ Develop Disaster Recovery Plan to manage paper client records ‘Develop formalized traning system for all users who create charge enya billing “CONFIDENTIAL Serer reece hesefil Sur thew eco mil cntoneasee Songun na Repo Enterprise Audit Provider Specific Methodology: PCG utilized a consistent, systematic approach to conducting the enterprise audit of Youth Development, In. (YDI). PCG began by locating YDI’s legal entity, its officers and organtzes CG also reviewed initia founding and leadership information on YOM. CG located and reviewed YDI's audited Financial statements and tax date, PCG recorded and reviewed recent officers, key employees, and independent contractors. PCG also searched for ‘ther entities owned by key employees and contractors. PCG located related paries and analyzed both the parties and the relationships, reviewing for potential conics of interes. PCG assembled the Financial data and analyzed it, looking at key ratios, trerds, and tracking variances. PCG tracked the organization's addresses and reviewed ownership of property 0 ‘or through the county assessor's oie. Finally, PCG performed media and cout record searches ‘on te organization or etd individuals. Youth Development In. sa member of Partners in Wellness which was reviewed simultaneously, Youth Development nc. has a related organization, YDI Foundstion, Ine. that exist to collect, manage, and distribute funds and properties forthe benefit ofthe organization, ‘The financial interests ofboth organizations are pooled in consolidated financial statements, ‘Audit Observations ‘Youth Development Inc. provides services wo youth of New Mexico including reside care, youth employment and education, counseling, outreach, substance abuse prevention, gang. Prevention and community corrections programs. we a = a ae los = | “ConA aami natn i oa ncaea arc CONSUL Fil Report | Shaleiary Ghever DalSanie Padilla Pauick A Baldonado Totnise Monae | Pena Conrad E Candelaria Mary Rose Holy ‘Augustine © | Baca soba ‘Melendez ‘Stephen Fortess Det Baca ‘VoiHeadsart Ryan Patek | Grego ‘Member Rarona Padilla ‘Member Financial Relationships “The president of YDI is also the President and CEO of YES Housing. YDI leases office space to YES and YDI leases commercial fice space from YES, of Fiadings and Recommendations List of Key Documentation Reviewed “DocumeatSourse F (applicabley “Gudited Financial Statements SSS TO ‘Form 990 (Nonprofi Ming) 2011, 2010, 2009 ‘Contracts Ot ae TORFIENTIAN Pacts