Provider Reviews

The Provider Review Group is responsible for reviewing and monitoring statewide utilization and program compliance of Medicaid fee-for-service providers.

The Group conducts post-payment reviews and researches complaints. Following a review, the Group may issue provider sanctions in accordance with applicable federal and state laws and regulations, including, but not limited to, educational letters, recovery of improperly paid funds, and request for a corrective action plan.

The Group is responsible for detecting and identifying patterns of provider fraud, reviewing provider records, claims and payments to determine whether fraud, waste and abuse exist.

The Group is responsible for referring suspected fraud cases to the MMAC Investigations Group for further and full investigations.

The Group is also responsible for providing information and assistance in developing laws, regulations and policies and procedures for detecting and preventing fraud, waste and abuse of the Missouri Medicaid Title XIX Program.

On-Site Review

Attempts may be made to notify you of the upcoming visit to your office, but under some circumstances, this may not be done.

You will be asked to provide a place where 2-4 staff can work. A tabletop, access to outlets to plug in scanners and laptops will be needed.

A list of participants being reviewed, dates of service and documentation needed will be provided. This can include but is not limited to medical records, invoices, appointment calendars, sign in sheets, signature logs, timesheets, invoices, proof of delivery, physician orders, certificates of medical necessity, plan of care, progress notes, travel logs, and trip tickets. You are required to produce all documentation which demonstrates that services billed to MO HealthNet were provided in accordance with the policies and procedures established by MO HealthNet. Documentation needed varies with the type of program.

You will be asked to provide a list of employees and Social Security numbers. This is used to check the Office of Inspector General’s exclusion list, the Family Care Safety Registry and employee disqualification list, as applicable. Proof of qualified trainings needed to provide the billed services may also be requested.

Managers and billers should be available to answer general questions and to explain the billing process.  You will be notified of the audit findings in writing.

Desk Review

A medical record request will be mailed to the address of record. The letter will identify the participant by name and Department Case Number (DCN) as well as specific or general dates of service needed. Often, the explicit records needed will be outlined such as timesheets, physician progress notes, etc.; however, the entire medical record for a specified period of time may be requested. A time frame is specified for the return of the records and a contact name is provided. Records may be copied and sent in paper form, faxed or, in the case of electronic medical records, they may be put on a CD. You are encouraged to call the requestor with questions about the transfer of medical records. No release of information is needed from the participant to send requested information to MMAC.

The records will be used to verify that services billed and paid by MO HealthNet are in accordance with established policy and procedure. You are strongly encouraged to make sure the information you send is complete. You will be notified of the audit findings in writing.