Effective August 28, 2014, licensed Physician Assistants will be able to submit enrollment applications to become Medicaid providers. These applications will not be immediately processed.
Until the necessary work is completed for the Physician Assistants applications to be processed and the enrollment to actually take place, Physician Assistants may still provide services and bill under their collaborating physician’s number.
The instructions and application forms are available on this web site in PDF format under the “Provider Enrollment Applications and Forms” tab. Applicants should print out the application forms and mail them to the MMAC Provider Enrollment Unit after they are completed, along with the required documentation listed on the forms.
Per 13 CSR 70-3.020, MMAC will notify providers within 60 days of receipt of their applications when it appears the applications will not be processed within 90 days of receipt. At this time, MMAC believes that MMAC and MO HealthNet will be able to process these applications and enroll the Physician Assistants by the end of the first quarter of 2015. At that time, MMAC will begin accepting these applications in electronic format.
Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Missouri contracted with Cognosante, LLC in December, 2011 to serve as Missouri’s RAC.
Also, as part of the Deficit Reduction Act of 2006, the Medicaid Integrity Program was established. This program utilizes Medicaid Integrity Contractors (MICs) to analyze Medicaid claims data to identify high-risk areas and potential vulnerabilities, as well as conduct post-payment audits.
Missouri’s MIC is Health Integrity, LLC. The MICs are assigned by geographic location.
Both the RAC and the MIC may utilize subcontractors. A list of the contractors’ and subcontractors’ names is located below. Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or one of the companies listed below, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
Currently, Missouri’s MIC is conducting audits of Missouri hospice providers. The MIC may request documentation that supports Medicaid-enrolled participants’ eligibility for hospice, and other documents to ensure proper billing.
The Missouri RAC is preparing to conduct audits of enrolled Missouri pharmacy providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing) and that proper quantities were billed. They may request documentation to include items such as a copy of the original prescription, the dispensing record, documentation of offer to counsel, and the signed delivery record.
The RAC is also preparing to conduct audits of enrolled Missouri durable medical equipment providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing). They may request documentation to include items such as precertification and prior authorization forms and supporting documentation, prescriptions, physician’s orders, invoices, proof of delivery, and certificate of medical necessity.
Medicaid Integrity Contractor (MIC): Health Integrity, LLC
Recovery Audit Contractor (RAC): Cognosante, LLC
RAC Subcontractors:
Recovery Audit Specialists LLC
CDR Associates
Missouri Regulation 13 CSR 70-3.020 (7) requires providers to inform the state of any changes affecting their MO HealthNet enrollment records. These changes, including change of address, are to be reported by the provider on specific forms within 90 days of the change (except for change of ownership or control, which must be reported within 30 days). In addition, section 2.2 of the MO HealthNet Provider Manual requires providers to notify the Provider Enrollment Unit (PEU) of a change of address.
In Missouri, these updates and changes are reported to the PEU at Missouri Medicaid Audit and Compliance (MMAC).
In accordance with the regulation above, the PEU at MMAC inactivates enrolled providers whose mail has been returned to MMAC or MO HealthNet as undeliverable. This action suspends providers’ claims for 180 days, during which time the claims are neither paid nor denied. If the provider does not submit an address update form to PEU by the end of the 180 days, the provider’s claims will then be denied. This is done to help ensure provider enrollment records are accurate. Upon receipt and processing of the required form for updates, provider numbers are reactivated by the PEU.
In order to update your address with Provider Enrollment, please submit a Provider Update Request form. If you know your enrollment has already been made inactive due to undeliverable mail, write RETURNED MAIL in the upper right hand corner of the Update Request form. This will alert Provider Enrollment staff to forward any mail that has been returned.
The complete regulation is located at https://www.sos.mo.gov/adrules/csr/csr.asp and the MO HealthNet Provider Manuals are located at https://mydss.mo.gov/mhd/provider-manuals.
There has been conflicting information posted on the MMAC website in regards to the Provider Certification Training Test date for December 2013. The next review and test will be provided on Friday, December 13, 2013. The review will start at 10:00 am and the test will begin at 1:30 pm.
Additionally, the Provider Certification Training Test dates for 2014 have also been posted. The schedule is as follows:
March 13, 2014
June 12, 2014
September 11, 2014
December 11, 2014
Please visit the provider certification training page at https://mmac.mo.gov/providers/hcbs-provider-certification-training/
for the updated information and additional information regarding Provider Certification Training.
The Missouri Medicaid Audit and Compliance Unit (“MMAC”) has scheduled provider update meetings for all Home and Community Based Services (HCBS) providers in October 2013. HCBS providers include: In-Home Service (IHS) providers, Consumer Directed Services (CDS) vendors, Residential Care Facilities (RCF)/Assisted Living Facilities (ALF) and Adult Day Care (ADC).
Three sessions are being offered to allow maximum participation. HCBS providers need to attend only one session as the same agenda will be presented for each day. Pre-registration is not required. Meetings will be held at the Harry S. Truman Building, 301 West High St., Room 490/492, Jefferson City, MO 65101. The dates are as follows:
Monday, October 7, 2013
10:00 AM to 2:30 PM
Tuesday, October 8, 201310:00 AM to 2:30 PM
Wednesday, October 9, 201310:00 AM to 2:30 PM
Tentative topics to be presented include:
Missouri Department of Health and Senior Services (DHSS) Reassessments Data Entry in the Web ToolMissouri Medicaid Audit and Compliance Unit (MMAC) HCBS Updates and Changes Enrollment Changes and Updates Who to Ask for Guidance Provider Review Audit Responsibilitie How to Prepare for an Audit What is Audited? Billing and Documentation Practices Investigations Investigation Responsibilities Program Violations vs. Law Violation Administrative Actions Sanctions That Exist for Violations Annual Application Process for IHS and CDS Providers Required Documents Timeline
Additional information:
The IHS provider is responsible for maintaining proof of attendance in the certified manager’s personnel file. Attendance at any one of the sessions listed above will fulfill the requirement in 19 CSR 15-7.021(14)(D).Any questions regarding this memorandum should be directed to MMAC – Provider Contracts via e-mail at mmac.ihscontracts@dss.mo.gov.
In order to effectively treat chronic pain, physicians rely on drug testing to monitor prescribed medications and drugs of abuse. Urine Drug Screening tests which provide qualitative or semi-quantitative initial screen or preliminary results may not be reported with a quantitative code, i.e., codes in the Therapeutic Drug Assay or Chemistry Sections of the CPT book.
Initial screening tests may be performed and billed at point of care or at independent / hospital laboratories, but not both. A second screening of the same urine specimen is considered medically unnecessary. It is the responsibility of the ordering physician to coordinate billing of initial screening tests.
Additionally, quantification of all drugs tested for in a urine drug panel, without regard to screening results, is considered medically unnecessary. Confirmation/quantification of any drug should be the result of an initial positive screen for a drug class, or where there is a documented medical necessity in the patient record for the identification/quantification of a specific drug.
The following paragraphs were added to provide clarity to the policy on urine drug testing:
Physicians Manual: Section 13.41.E
Qualitative and semi-quantitative drug screening tests are covered by the MO HealthNet Program. Refer to the CPT book for appropriate procedure codes to reflect testing on single or multiple drug classes. A drug screen test reports what drug classes (e.g., tricyclic antidepressants, phenothiazines, amphetamines, benzodiazepines, barbiturates, cannabinoids, methadone, opiates) are present (qualitative) and may provide an estimate (semi-quantitative) of the concentration. An initial drug screen or preliminary test that yields qualitative or semi-quantitative results must be reported with an appropriate drug testing procedure code categorized as such in the CPT book. Codes in the Therapeutic Drug Assay or Chemistry Sections of the CPT book may not be used to report qualitative or semi-quantitative drug screening and preliminary test results. Physician offices may bill for initial drug screens performed at point of care (e.g., by use of CLIA waived test devices) or independent and/or hospital laboratories may bill for screenings they performed, but both cannot be billed. It shall be the responsibility of the ordering physician to coordinate with the performing laboratory for the billing of drug screen tests.
Providers should not routinely bill for the quantification of drug classes. Providers should only bill for the quantification of a drug class or a confirmatory drug test (i.e., billing procedure codes from the Therapeutic Drug Assay or Chemistry sections of the CPT book) if there is a positive screen for the drug class to be quantified.
MO HealthNet Division
P.O. Box 808001
Kansas City, MO 64180-8001
The participant must put their MO HealthNet number (case number) on the check or money order. They should mail their payment along with the invoice stub for the month for which they are paying. If they do not have the correct invoice stub to send, they must write on the check or money order what month they are paying for. They must not send an old invoice to pay for a current month. Option 2: Participants may have their payment taken directly out of their bank account on the 10th of each month by the MO HealthNet Division to pay for their spend down obligation for the following month. To have their payment automatically taken from their bank account the participant must complete the Spend down Automatic Withdrawal Form. They must allow 30 days for the automatic withdrawal to process. The participants cannot use bills to meet their spend down if they chose to have the payment taken from their bank account each month through automatic withdrawal. If the participant has insufficient funds to cover the automatic withdrawal, they must send either a money order or cashier’s check to cover the insufficient payment.
If the participant changes banks or changes accounts within their bank, they will need to submit a new automatic withdrawal form (https://dss.mo.gov/mhd/participants/pdf/awa-spenddown.pdf) marked “change,” and will need to allow 30 days for this change to take place. Amounts and Submission of Invoices for private pay services delivered when the recipient is not receiving MO HealthNet benefits (not active on Medicaid) to meet Spend Down: The invoice/bills may be submitted by the provider on behalf of the patient or by the patient directly. Home Health services may be billed to the patient at the agencies usual and customary (private pay) rate (for the same service). CDS and Personal Care services authorized by the Department of Health and Senior Services are allowed to meet spend down but must be billed at the state rate (the Medicaid reimbursement rate for the service). Personal care services that are not authorized by the Department of Health and Senior Services but are medically necessary as prescribed by a physician are allowed to be billed at your usual and customary (private pay) rate. However, you must submit the physician’s order for these services along with the invoice/bill that is submitted to FSD. FSD will review each of these cases and consult with DSDS when necessary. Documenting in-home tasks/time: If you are providing personal care to a DSDS in-home or CDS client on a private pay basis at the beginning of the month during the period of time that the client has not met spend down, you do not have to document every task (5 minutes to brush teeth, 20 minutes to help with bathing, etc.). You may bill for the hour(s) of personal care authorized and delivered. Obviously you can only bill for a service that you provided and for the amount of time it takes (in total) to deliver. So if you were providing 2 hours of personal care and during those two hours you provided assistance with bathing, toileting, meal prep, etc. you do not have to list each of the tasks you provided just list that you provided 2 hours of personal care, the date, the worker, etc.
In an effort to help states reduce improper payments for Medicaid health care claims, the Centers for Medicare and Medicaid Services (CMS) issued a final rule to implement section 6411 of the Affordable Care Act.
Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor allowing states to reimburse contractors who assist in the identification and recovery of improper payments. The RAC program has been used in the Medicare program and is now being required for Medicaid. The mission of the RAC program is to reduce improper payments in Medicaid through the efficient detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.
The State of Missouri, Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC), contracted with Cognosante, LLC, to be the Medicaid Recovery Audit Contractor. Cognosante is also the NPI Enumerator for CMS and has helped more than three million providers nationally obtain NPI numbers.
Cognosante began sending overpayment letters to certain providers last week. The overpayment letters contain information on repayment options, appeal information, and where to go for questions. The telephone number for Cognosante’s Customer Service Center is (855) 667-2212 or you can email questions to MissouriRAC@cognosante.com
In order to facilitate the enrollment process, please fax all documentation other than the “signature” page to (573-751-5065) or you may scan and email the verification documentation to mmac.providerenrollment@dss.mo.gov, which may include tax documents, Medicare enrollment verification, Board of Healing Art licensure, or other verification documentation for enrollment. The Provider Enrollment Unit also has an auto-responder that confirms the receipt of the e-mail. “Signature Pages” MUST still be faxed to (573-634-3105) until further notice.
MMAC is responsible for administering and managing Medicaid (Title XIX) audit and compliance initiatives and managing and administering provider enrollment contracts under the Medicaid program. MMAC is charged with detecting, investigating and preventing fraud, waste and abuse of the Medicaid Title XIX, CHIP Title XXI, and waiver programs. For additional information about MMAC visit their website at https://mmac.mo.gov/.
In an effort to help states reduce improper payments for Medicaid health care claims, the Centers for Medicare and Medicaid Services (CMS) issued a final rule to implement section 6411 of the Affordable Care Act.
Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor allowing states to reimburse contractors who assist in the identification and recovery of improper payments. The RAC program has been used in the Medicare program and is now being required for Medicaid. The mission of the RAC program is to reduce improper payments in Medicaid through the efficient detection and collection of overpayments, the identification of underpayments, and the implementation of actions that will prevent future improper payments.
The State of Missouri, Department of Social Services (DSS), Missouri Medicaid Audit and Compliance Unit (MMAC), contracted with Cognosante, LLC, to be the Medicaid Recovery Audit Contractor. Cognosante is also the NPI Enumerator for CMS and has helped more than three million providers nationally obtain NPI numbers.
Cognosante will begin RAC audits by focusing on three (3) program areas – Durable Medical Equipment (DME), Behavioral Health Services, and retail Pharmacy. Providers with improper payments will receive certified letters from Cognosante on behalf of MMAC. If providers disagree with a decision made by the RAC contractor, they may exercise their appeal rights through the Administrative Hearing Commission. Letters will contain information on repayment options, appeal information, and where to go for questions.
Traditionally, MMAC post-payment review audits focus on medical records documentation. Cognosante will conduct post payment audits driven by established Missouri and industry rules.
Cognosante will have a Call Center available for RAC questions/issues related to audits. The phone number will be published in a future provider email notification and will be published at https://mmac.mo.gov/.
For non-audit RAC comments/concerns, please direct comments or questions to email address dss.mmac.compliance@dss.mo.gov or to Pamela Hendrix at 573-526-5743.
MMAC is responsible for administering and managing Medicaid (Title XIX) audit and compliance initiatives and managing and administering provider enrollment contracts under the Medicaid program. MMAC is charged with detecting, investigating and preventing fraud, waste and abuse of the Medicaid Title XIX, CHIP Title XXI, and waiver programs. For additional information about MMAC visit their website at https://mmac.mo.gov/.—
