The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain drugs. In order to collect accurate data for the rebate process, all incorrectly billed pharmacy claims must be corrected in the Medicaid billing system so accurate drugs and quantities are reported. Therefore, providers who wish to self-disclose incorrectly billed pharmacy claims to Missouri Medicaid Audit and Compliance (MMAC) are asked to not submit a check.
Instead, the claim number(s) (ICN) should be reported on the self-disclosure form along with a clear explanation of the error; MMAC staff will then correct the claim(s) in the billing system and the correction will show up as such on the corresponding Remittance Advice (RA). Click here to access the self-disclosure form. If you have any questions, please contact MMAC at mmac.providerreview@dss.mo.gov
As reported in a previous gov.delivery message by Missouri Medicaid Audit and Compliance (MMAC), HMS will soon begin conducting credit balance audits on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and MMAC. Click here to view the original message and website post.
When your long-term care facility is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS. MMAC will also notify the Missouri Health Care Association and LeadingAge Missouri. Long-term care facilities can expect to begin receiving letter regarding the credit balance audits after May 1, 2016.
Long-term care facility audits will be Medicaid-specific, and will be “desk audits”, where HMS will request that you send them information. This means HMS will not come on-site to conduct the audit.
Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.
HMS has prepared its initial schedule for long-term care facility audits.
Review Start Date Provider Name 6/1/2013 BLUFFS (THE) 6/1/2013 GIDEON CARE CENTER 6/1/2013 GOWER CONVALESCENT CENTER 6/1/2013 LAVERNA VILLAGE OF ST JOSEPH 6/1/2013 LUTHERAN SENIOR SERVICES 6/1/2013 MARY QUEEN AND MOTHER CENTER 6/1/2013 MILAN HEALTH CARE CENTER 6/1/2013 VILLA MARIE-A STONEBRIGDE COMMUNITY 6/1/2013 VILLAGES OF JACKSON CREEK, THE 6/1/2013 WESTWOOD HILLS HEALTH & REHABILITATION C
If you have any questions, please contact MMAC at tricia.smith@dss.mo.gov
As reported in a previous gov.delivery message by Missouri Medicaid Audit and Compliance (MMAC), HMS will soon begin conducting credit balance audits on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and MMAC. Click here to view the original message and website post.
When your hospital is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS. MMAC will also notify the Missouri Hospital Association. Hospitals can expect to begin receiving letters regarding the credit balance audits after May 1, 2016.
Hospital audits will be Medicaid-specific, and may be desk audits, where HMS will request that you send them information; or, the audits may be completed on-site.
Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.
HMS has prepared its initial schedule for hospital credit balance audits. Click here to view the schedule.
If you have any questions, please contact MMAC at tricia.smith@dss.mo.gov
Credit balances on patient accounts occur for a variety of reasons. For instance, providers sometimes receive duplicate payments, charges may be reversed, billing data may be incomplete, and third party liabilities may be incorrectly applied. Providers routinely identify and refund these credit balances (overpayments), but sometimes the ability to refund the overpayment in a timely fashion is constrained by limited resources or imperfect information. Sometimes, providers aren’t aware the overpayments exist. Not all credit balances result in an overpayment, and out of those, not all require a refund; some simply require an adjustment.
HMS will soon begin conducting credit balance audits, on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and Missouri Medicaid Audit and Compliance (MMAC). When your hospital or nursing home is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS. MMAC will also notify the Missouri Hospital Association, Missouri Health Care Association, and LeadingAge Missouri.
Nursing home audits will be conducted as “desk audits”. This means that HMS will review the patient accounts off-site after receiving any necessary documentation from the nursing home. These audits will be specific to Medicaid patients (participants.)
Hospital audits will be Medicaid-specific, as well. Hospital audits may be desk audits, or they may be completed on-site.
Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.
Missouri State Regulation requires documentation of a pharmacist’s offer to counsel, for all MO HealthNet participants’ prescriptions. The regulation states, “Documentation of Offer to Counsel: The pharmacist shall document for each MO HealthNet patient’s prescription in a uniform fashion, whether the offer to counsel was accepted or refused by the patient or the patent’s agent. “ Click here to read the regulation: 13 CSR 70-20.310(7).
Additionally, pharmacies must obtain the signature of the participant or his/her representative, and the relationship of the representative to the participant. Participants living in long-term care facilities such as nursing facilities, ICF/MR facilities, and psychiatric residential treatment facilities are granted an exemption from this requirement.
The signature log serves as verification that the participant received the prescription dispensed. One signature per prescription is required, and electronic signatures are acceptable. Providers must make the signature log and offer to counsel available upon request by MO HealthNet or MMAC. More information about signature log requirements is found in the MO HealthNet Pharmacy Manual. Click here to access the manual.
Please contact Missouri Medicaid Audit and Compliance (MMAC) at MMAC.PROVIDERREVIEW@DSS.MO.GOV if you have any questions
Missouri Medicaid Audit and Compliance (MMAC) is responsible for reviewing Medicaid (MO HealthNet) participants who may be subjecting the Medicaid program to fraud, waste, and abuse due to mis-utilizing or over-utilizing some of their MO HealthNet benefits. MMAC will review the number of physicians prescribing services to a particular participant, the number of pharmacies used by the participant to obtain prescriptions, the frequency of refills or overlapping prescriptions, the number of emergency room visits, and the services received by the participant.
If a MO HealthNet participant is determined to by mis-utilizing MO HealthNet benefits, he or she can be restricted to a physician/clinic, pharmacy, or both, in accordance with 13 CSR 70-4.070. This restriction is called “Locked In”. The Lock-In program is also described in the MO HealthNet Physician Manual.
When a participant is “locked in” to a specific provider, the provider’s name and telephone number are identified on the internet, IVR, or point of service terminal used when verifying eligibility. Payment for services for a “locked-in” participant will not be made to unauthorized providers, except for emergency services, and authorized referral services. Emergency services must be supported by medical records documenting the emergency circumstances.
The designated (authorized) “lock-in” provider is responsible for the participant’s primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary, the authorized physician must complete a Medical Referral Form of Restricted Participant (PI-118) and send it to the provider to whom the participant is referred.
The referral forms are available on the MMAC website. Click here to access the forms.
The referral is good for 30 days only from the date of service. The Reason for Referral field should be completed on the form, and the form must contain the NPI (and taxonomy code if appropriate) of the authorized provider. If the participant is locked into a clinic, use the clinic’s NPI (not the individual physician’s). The form must be submitted by the unauthorized provider via the internet at www.emomed.com, or mailed to Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102.
Read more about the Participant Lock-In Program at the MMAC website.
