Missouri Medicaid Audit and Compliance (MMAC) has received inquiries from personal care providers, regarding MMAC audit guidelines. Providers want to know what types of documents MMAC auditors will request, as well as what constitutes adequate documentation. Providers also want to know what to expect during an audit.
The following information is intended to assist you in the event MMAC requests that you send in records, or if MMAC auditors come on-site to scan records for an audit.
DESK AUDIT:
MMAC auditors may choose to conduct a “desk audit”, meaning they will request that you send records, without paying you a visit in person. If this happens, you will receive a request for records that will include the following:
- the dates of service being reviewed
- the participants being reviewed
- the participants’ dates of birth
- a list of the requested documentation (see below under “Required Records”)
- the deadline to submit the records
- if records are missing from what you submit, it is usually appropriate for the auditor to contact you to let you know, so be sure the auditor has good contact information for you. Providers should always keep their information up-to-date, per state regulation. (13 CSR 70-30.020 states providers must notify the State of any updates affecting their enrollment records within 90 days, unless it’s a change of ownership, and that notification must be made within 30 days.) Click here to read that regulation.
ON-SITE AUDIT:
MMAC auditors may conduct an on-site visit. If they do, they will usually call you at least one day prior to their arrival. They will generally be able to let you know their estimated arrival time and the time period being reviewed (dates of service for the audit). The auditors will ask you for a contact person, and they will do their best to let you know how many MMAC auditors will be on-site (our auditors usually travel in pairs). They will talk to you about where they can set up their scanners and laptops, and they will generally provide you with a partial list of participants’ names so some records can be pulled in advance, to minimize time on-site.
Once on-site, the auditors will give you the complete list of participant names included in the audit. They will provide you with a notification letter for your records. Auditors will ask you if you have a copy of, or access to, the MO HealthNet provider manuals and bulletins. These are available via the internet at these locations: MHD provider manuals. MHD provider bulletins. If you need assistance locating these or signing up for updates, the auditors will assist you. Auditors will then scan the requested documentation (see below).
Auditors should generally ask you if they notice missing documentation or if it appears you might refer to a document by a different name.
Before leaving the audit site, auditors will complete a Billing Checklist with you. This helps the auditor understand your billing procedures. The auditor will complete a Documentation Disclosure Statement with you. Any missing documentation that the auditor is aware of, will be noted on the form. The auditors will hold an exit conference with you if you like.
After returning to the office, the lead auditor will complete the audit. The completed audit may indicate there are no findings or violations noted. You will receive a “no findings” letter. If there are violations noted, the auditor will compile those as an attachment for you, and you will receive notice of the completed audit and the noted violations. The auditor will determine the appropriate sanction by following the guidelines in state regulation 13 CSR 70-3.030 (click here to view). The appropriate sanction could include education, or recoupment of improperly paid claims (“overpayment”). The attachment you receive will clearly indicate the sanction for each error.
Some audits result in MMAC’s Investigations Unit opening an investigative case. This could be due to complaints or referrals received on the provider, suspicious or concerning audit findings, or other factors. Generally, if a completed audit becomes part of an investigation, you will not receive your “no-findings” or “findings” letter as quickly. With personal care services, the investigation may be specific to an aide(s) or attendant(s), or the biller, and not necessarily the provider as a whole, although that sometimes occurs. If you feel it has been a long time since your audit, and you have not heard from MMAC about the results, you should feel free to contact us.
If your audit results include recoupment for errors found, you will receive notice about how to appeal the decision, in your letter. As well, MMAC contact information is included in the letter in case you have any questions.
REQUIRED RECORDS:
Auditors may ask for the following documentation:
- Participants’ care plans (Web Tool print-out or LTACS)
- Any and all documents to support services billed (such as nurse visit reports and time sheets, or EVV reports)
- Copies of employees’ initial FCSR screenings for all employees who provided services to the participants in the audit during the audit time frames
- Additional information about those employees, to include complete name (current and former), home address, date of hire and date of first client contact, and termination date if applicable
- A sample of a complete participant file
- A sample of a complete employee file
- Documentation for a few employees that verifies initial and ongoing training requirements were met. This includes classroom and on the job training.
- Verification of liability insurance coverage and a dishonesty bond
DOCUMENTATION REQUIREMENTS:
For in-home personal care, homemaker, and respite services, documentation must include the following:
- The participant’s name
- The date of service delivery, including year
- The time spent providing the service (actual clock time the aide began the service for each visit is the start time; the actual clock time the aide finished the care for the visit is the stop time)
- A description of the service (tasks performed- but not required for respite)
- The name of the aide who provided the services
- The signature of the participant for each date of service (if the participant is unable to sign, there are substitutions available per state regulation – see list of applicable program regulations, below)
For Advanced Personal Care (APC) services, auditors will review the following documentation, as well:
- Documentation to show the aide performing APC tasks was qualified to do so, by being a Licensed Practical Nurse (LPC), a Certified Nurse Assistant (CNA), or by being a competency evaluated home health aide who has completed both written and demonstration portions of the test required by the Missouri Department of Health and Senior Services, or having worked successfully for the provider for a minimum of three consecutive months while working at least 15 hours per week as an in-home aide who has received Personal Care training.
- Auditors will review the employee file for documentation to show the aide performing APC tasks received proper training, has the proper license or registration in Missouri, and that the aide has successfully completed on the job training for each APC task he or she has performed.
CONSUMER DIRECTED SERVICES:
For Consumer Directed Services, auditors will also ensure the following:
- The caregiver is not the spouse
- Medicaid was not billed for Authorized Nurse Visits (Authorized Nurse Visits may only be billed under the In-Home Program, not CDS)
- There is evidence the consumer was trained by the Consumer Directed Services Vendor
- The appropriate tax forms have been completed and turned in
RULES AND REGULATIONS YOU SHOULD KNOW:
Please contact MMAC at MMAC.Providerreview@dss.mo.gov with any questions regarding this information.