The Missouri Medicaid Audit and Compliance (MMAC) will not be scheduling provider update meetings for Home and Community Based Services (HCBS) providers for the remainder of this calendar year. HCBS providers include: In-Home Service (IHS) providers, Consumer Directed Services (CDS) vendors, Residential Care Facility (RCF)/Assisted Living Facility (ALF) Personal Care (PC) providers and Adult Day Health Care (ADHC) providers.
In accordance with the 19 CSR 15-7.021(14)(D), In-Home Service Standards, each IHS provider is to “ensure the designated managers annually attend division-sponsored training designed to update certified managers.” Certified managers will not be penalized for not completing the annual training requirements for calendar year 2012. A copy of this letter should be maintained as proof that the training requirement was waived for 2012.
The provider should not submit claims solely on the basis of the prior authorization, but must base claims upon documentation of actual services rendered. The participant may have been in the hospital or nursing home during a month, may have been away from the home visiting family or friends, or there may have been other reasons why all services which were prior authorized were not necessary or could not be delivered. The prior authorization merely establishes the maximum number of hours and types of services which may be given to a participant during a time period. All units billed to MO HealthNet must be supported by the documentation of delivery as described in this section.
Pursuant to the above, providers can only bill for actual services rendered. If, for example, a month only has 28 days, the provider cannot provide services on the 29th, 30th or 31st day. Specifically, if a service is authorized to be provided once a day, and the month only has 28 days, then the service can only bill for the days service provided up to a maximum of 28 days.
2. Question: How will MMAC conduct audits with regard to signatures? MMAC has posted guidance on this issue on its website. 3. Question: How will MMAC conduct audits with regard to nurse visits? Specifically, is a pre-printed form acceptable with a short narrative or short notes, and a signature (a form with check boxes), or does the whole form need to be handwritten? A pre-printed form is acceptable with a short narrative or short notes, and a signature. The whole form does not have to be hand-written. If, however, the type of information required to be documented is not susceptible for being captured in a pre-printed form, then the information must be supplied. For example, if the required information is to provide the participant’s vital signs, a “check the box” option would not be acceptable. The participant’s actual vital signs must be documented on the form. 4. Question: Is it acceptable for an LPN to do certain activities on the authorized nurse visit, as opposed to an RN? 13 CRS 70-91.010(6)(0)4 provides: The RN may provide nail care for a diabetic or client with other medically contraindicating conditions, if the recipient is unable to perform this task.Although section 335.099 RSMo states LPNs are “qualified” to perform certain services, it uses the qualifier “as required by the department of social services”. The Department of Social Services requirements include that the LPN’s work be under the direction of an RN. The Missouri State Medicaid Plan specifies that nurse services and personal care oversight are to be provided by an RN. For that reason, the Department of Social Services requires that the LPN’s work be under the direction of an RN. 13 CSR 70-91.010(6)(0)7 provides: The visits authorized under subsection (6) except (6)(0)6 may be carried out by an LPN, if under the direction of an RN.Section 13.8 of the MO HealthNet Medicaid Personal Care Manual states: The authorized nurse visits listed above may be provided by an LPN, if under the direction of an RN, except an RN must perform the on-the-job training and competency testing for advanced personal care aides.In order to comply with the above, MMAC requires documentation to prove that there is an RN on staff with the agency.
Personal Care Services Provided in a Residential Care Facility Setting or the Participant’s Home
Please note that, pursuant to 13 CSR 70-91.010(4)(A) 2.F., documentation for services delivered by the provider in the Personal Care Program must include the following:
F. For each date of service: the signature of the recipient, or the mark of the recipient witnessed by at least one (1) person, or the signature of another responsible person present in the recipient’s home or licensed Residential Care Facility I or II at the time of service. “Responsible person” may include the personal care aide’s supervisor, if the supervisor is present in the hom e at the time of service delivery. The personal care aide may only sign on behalf of the recipient when the recipient is unable to sign and there is no other responsible person present.
Please also note that the MO HealthNet Personal Care Program Manual 13.7.D(1) states:
6. For each date of service: the signature of the participant, or the mark of the participant witnessed by at least one person, or the signature of another responsible person present in the participant’s home or licensed Residential Care Facility I or II at the time of service. A responsible person may include the personal care aide’s supervisor, if the supervisor is present in the home at the time of service delivery. The personal care aide may only sign on behalf of the participant when the participant is unable to sign and there is no other responsible person present. The entire signature of the participant or witness to the mark or the responsible party must be present in the record for each date of service billed to MO HealthNet. Initials are not acceptable in lieu of the entire signature. The participant’s DCN is not required on the time sheet.
The regulation and the manual do not establish a hierarchy of preferences regarding the signature. As long as the signature of the recipient (in its entirety; initials are not permitted), the witnessed mark of the recipient (the witness’s entire signature must be present; initials of the witness are not permitted) or the signature (in its entirety; initials are not permitted) of another responsible person present in the recipient’s home or RCF I or II at the time of the service (“responsible person” may include the personal care aide’s supervisor, if the supervisor is present in the home at the time of service delivery) is present for each date of service, then the above- requirements will be fulfilled. However, the personal care aide may only sign on behalf of the participant when the participant is unable to sign and there is no other responsible person present (the reason for the participant’s inability to sign must be documented.
The same standards apply if a recipient has made a blanket signature statement, such as, “the requirement is too burdensome and I therefore authorize the provider’s staff to sign on my behalf.” If the recipient has chosen to do this, the entire signature of the other responsible person must still be present for each date of service. The personal care aide still may only sign when there is no other responsible person present, and in such case, the recipient must be unable to sign. Documentation must be provided to support the reason the recipient was unable to sign.
In a Residential Care Facility setting, note that all tasks performed for each recipient by date of services and by staff shifts during each twenty-four (24)-hour period must be documented. For example, if three (3) aides provide services to one recipient in a twenty-four (24)-hour period, each aide must document all tasks performed by each recipient by date of services, but the recipient need only sign (in accordance with the above-guidance) once in the applicable (24)- hour period.
Missouri state law (RSMO 345.020) prohibits anyone from practicing speech-language pathology without a Missouri license.
RSMO 345.025.1(6) provides: The provisions of sections 345.010 to 345.080 do not apply to an individual who “holds a current valid certificate as a speech-language pathologist issued by the Missouri Department of Elementary and Secondary Education (DESE) and who is an employee of a public school while providing speech-language pathology services in such school system”.
There are three different ways to obtain a speech language pathologist student services certificate from DESE:
A certificate will be issued if the person holds a valid Missouri license from the Board of Healing Arts. This certificate is valid for as long as the license is current. If the license becomes inactive, the certificate is no longer valid. A certificate will be issued if the person completes a Teacher Preparation Program with sufficient credits in speech pathology. This certificate is valid for 99 years. A certificate will be issued if the person has completed a teacher preparation program in another state and holds a valid teaching certificate in speech pathology or something comparable from another state. This certificate is valid for 99 years.If a speech language pathologist’s certificate was issued based on holding a valid Missouri license and the Missouri license is no longer current, the certificate becomes invalid. As a result, the speech language pathologist’s enrollment in the Missouri Medicaid program will be terminated.
The Missouri Medicaid Audit and Compliance Unit requests that any provider who believes that documentation in support of servicing Missouri Medicaid participants is no longer available, due to extenuating circumstances or unforeseen events, utilize the Attestation of Medical Record Loss or Destruction Form which can be found at:
https://mmac.mo.gov/providers/provider-enrollment/provider-enrollment
The following may be a useful resource, but is not intended to be a treatise on federal fraud and abuse laws or answer specific legal questions of providers. Rather, it serves as a basic understanding of the federal Anti-Kickback statute (AKS) and Civil Monetary Penalties law (CMPL) as they may apply to providers. MMAC encourages you to consult with your legal counsel for specific advice.
The federal AKS and CMPL are two important tools used by the federal Department of Health and Human Services Office of Inspector General (OIG) to combat health care fraud and abuse. Both the AKS and the CMPL apply to transactions reimbursed by Federal health care programs, including Medicare and Medicaid. The AKS is a criminal law, while the CMPL is a civil law. Violations of the AKS include administrative penalties, fines of up to $50,000 per kickback plus three times the amount of the kickback, and potential jail time. A violation of the AKS is also an automatic violation of the CMPL. Violations of the CMPL result in administrative penalties and fines of $10,000 to $50,000 per violation. Administrative penalties for both can, and in some cases must, result in exclusion from participation in Federal health care programs.
The AKS prohibits the knowing and willful payment and receipt of remuneration to induce or reward patient referrals or the generation of business involving any item or service payable by Federal health care programs. This is true where even one purpose of the remuneration is to reward the referral of services or induce further referrals. “Remuneration” for the purposes of the AKS includes the transfer of anything of value, directly or indirectly, overtly or covertly, in cash or in kind. This definition includes money, but can also include free rent, grass-cutting, shopping, transportation, and waiver of co-payments or co-insurance for Federal health care program beneficiaries. Congress and the Secretary of Health and Human Services have developed protections for certain arrangements that have come to be known as safe-harbors. Arrangements that might otherwise be illegal under the broad proscription of the AKS can be protected by meeting the requirements set forth in the safe-harbors.
The CMPL addresses, among other things, the transfer of or offer to transfer remuneration to a Medicare or state health care program (including Medicaid) beneficiary. Penalties can result where the benefactor knows or should know that remuneration is likely to influence the beneficiary to order or receive from a particular provider, practitioner, or supplier any item or service for which payment may be made, in whole or in part, by Medicare or a state health care program (including Medicaid). “Remuneration” for the purposes of the CMPL includes transfers of items or services for free or for other than fair market value. It can also include waiver of even part of the beneficiary’s co-insurance or deductible amounts. It does not include anything that promotes access to care and poses a low risk of harm to patients and Federal health care programs. The OIG has previously taken the position that nominal incentives are not prohibited by the CMPL and defined nominal as no more than $10 per item or $50 total on an annual basis.
Federal health care fraud and abuse laws like the AKS and CMPL seek to reduce the overutilization of services, reduce government health care costs caused by the overutilization of services for Federal health care program beneficiaries, and shift the focus of medical care to what is most medically appropriate for the patient rather than what is most lucrative for the health care provider. Because of the potential penalties associated with violations of the AKS and CMPL, awareness of these laws is vital for health care providers. Compliance with the AKS and CMPL is highly fact-specific, and so health care providers are encouraged to consult with legal counsel when questions arise.
LimitationsThe limitations applicable to this Memorandum include the following:
This Memorandum has no application to, and cannot be relied upon by, any individual or entity and does not affect the legal rights of, or procedures available to, the public or any segment thereof. This Memorandum may not be introduced into evidence in any matter involving an entity or individual.revised 1/28/13
Follow the current care plan as closely as possible Never serve more than approved units Intermittent changes: If the services provided do not substantially match the care plan, document why and attach the documentation to the time sheet. Permanent changes: If the units need to be decreased or increased contact DHSS and document the date of that contact in the participant record. If a participant does not want a certain service on the care plan, call DHSS for a care plan change. Example: A participant tells an aide that s/he does not want the aide to bathe her because s/he has made other arrangements. DHSS should be contacted to reduce the care plan. Document the date of that contact in the participant record. Listed below are the types of documentation MMAC Provider Review may request but are not limited to: Time sheets/telephony records Current care plan and LTACS/Web Tool Nurses Notes Training Records Employee Records Any other documents maintained by the provider that would support billings to MO HealthNet. Residential Care Facilities: Provide the services that on the current care plan Bill only for the days that services are provided. This will not always be 31 days. Times sheets must be signed daily per regulation 13 CSR 70-91.010(4)(A)2.f. Intermittent changes: If the services provided do not match the care plan, document why and attach the documentation to the time sheet. Permanent changes: If the units need to be increased or decreased, contact DHSS and document the date of the contact in the participant record. Listed below are the types of documentation MMAC Provider Review may request but are not limited to: Service delivery logs Written notes and observations Daily nursing chart Medication Administration Records (MAR) Census records Current care plan and LTACS/Web Tool Any other documents maintained by the provider that would support billings to MO HealthNet.ABUSE: Provider practices that are inconsistent with sound fiscal, business, or medical practices and result in an unnecessary cost to the Medicaid program, or in reimbursement for services that are not medically necessary, or that fail to meet professionally recognized standards for health care. It also includes recipient practices that result in unnecessary cost to the Medicaid program. 42 CFR§455.2.
ACCEPTED REFERRAL: Referral of a potentially fraudulent Medicaid provider to the State’s Medicaid Fraud Control Unit (MFCU) that is accepted by the MFCU.
ADMINISTRATIVE ACTION: Provider sanction, payment suspension or other action taken by the State against a Medicaid provider before a determination of Medicaid fraud, waste or abuse or overpayment has been made.
ALGORITHM: A set of well-defined rules or procedures for solving a problem in a finite number of steps.
AUDIT: An assessment, evaluation, inspection, or investigation of services rendered or items furnished by a Medicaid provider.
AUDIT, DESK: An audit that is wholly or principally carried out in the office(s) of the auditor.
AUDIT, FIELD: An audit that is carried out at the office(s) of the organization being audited or includes a substantial “on-site” component.
AUDIT, FOCUSED: A review of services rendered or items furnished by a Medicaid provider that is limited in scope to a specific set of services or items or particular inappropriate billing practices.
AUDIT, PROVIDER SELF: An audit that is carried out wholly or principally by the provider being audited.
CASE: An investigation by a Medicaid Program Integrity office, a Medicaid Fraud Control Unit, or other Agency, to determine whether there has been a violation by a Medicaid provider of Medicaid laws, rules, or regulations or accepted standards.
CIVIL MONETARY PENALTIES: Any money penalty, imposed by either CMS or OIG against individuals/entities for conduct that violates Federal and/or State statutes and regulations governing the Medicaid program. 42 CFR Part 402.
CLAIM: A request for payment for services and benefits rendered by a Medicaid provider, also known as bills or invoices.
COLLECTIONS: Cash recovered in reimbursement of overpayments or other cash received as a result of Medicaid program integrity activities.
COMPREHENSIVE MANAGED CARE: Managed care plans (e.g., Health Maintenance Organizations, Preferred Provider Organizations) that provide health services on a prepayment basis, which is based either on cost or risk, depending on the type of contract. 42 CFR Part 438.
COST AVOIDANCE: An action or intervention that reduces or eliminates a cost or outlay that would have occurred if not for that action or intervention.
COST REPORT: Report required from providers on an annual basis in order to make a proper determination of reimbursement rate under the Medicaid program based on the expenses incurred by the provider in the course of supplying services.
CREDENTIALING: Review procedures conducted for the purpose of determining whether a potential or existing provider meets certain standards that are a prerequisite for them to begin or continue participation in a given health care plan.
DATA MINING: The analysis of large volumes of data maintained in databases or data warehouses using query tools, algorithms, and models to identify patterns, trends, and relationships or correlations among the data and to develop useful information for investigative and management purposes.
DATA WAREHOUSE: A relational database designed for query and analysis, rather than for transaction processing. It usually contains historical data derived from transaction data, but can include data from other sources. It separates analysis workload from transaction workload and enables an organization to consolidate data from several sources.
DETECTION: Activities such as data mining, auditing, surveillance utilization and reviews or other methods, aimed at identifying possible fraud, waste, and abuse in the Medicaid program.
DISTINCT PROGRAM INTEGRITY MODEL: Organizational structure in which a distinct Medicaid program integrity unit exists within the State. Medicaid Integrity activities such as prevention, detection, audit and investigation lie wholly within the State Medicaid Agency but are not necessarily centralized in a Medicaid “Program Integrity Unit.”
DOLLARS IDENTIFIED FOR RECOVERY: Represents the dollar amount of claims inappropriately paid as identified by data mining, audit, surveillance utilization review or other methods.
DOLLARS RECOVERED: Represents total dollar amount of overpayments actually recovered by the State (as opposed to dollars identified or an agreement by the provider to refund the program).
EDITS: “Front end” reviews or controls in the Medicaid Management Information Systems (MMIS) that examine the information in each claim in relation to certain Medicaid policies and to other claims, and cause the claim to be paid, pended, or denied.
ENCOUNTER DATA: Data related to the services and items received by a Medicaid recipient in an encounter with or visit to a Medicaid provider through managed care. Also referred to as “shadow claims”.
ENROLLMENT: The process of admitting (or not admitting) a prospective provider or recipient into the Medicaid program or a component of the program, such as managed care.
EXCLUDED INDIVIDUALS OR ENTITIES: Individuals or entities that have been placed in non- eligible participant status under Medicare, Medicaid and other Federal or State health care programs. Exclusions may occur due to OIG sanctions, failure to renew license or certification registration, revocation of professional license or certification, or termination by the State Medicaid Agency.
EXCLUDED PARTIES LIST SYSTEM (EPLS): An electronic, web-based system http://www.epls.gov maintained by the General Services Administration (GSA) that identifies those parties excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non-financial assistance and benefits. *Note: The General Services Administration (GSA) has migrated data from the well known Excluded Parties List System (EPLS) to a new and more comprehensive system call the System for Award Management (SAM).
EXPENDITURE: Refers to funds spent as reported by the State.
EXTRAPOLATION: The process of predicting a future cost (or other measure) using current data or results from the past.
FEE-FOR-SERVICE (FFS): Traditional method of payment for medical services where payment is made to providers for each service rendered.
FRAUD: An intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person. Includes any act that constitutes fraud under applicable Federal or State law. 42 CFR 455.2.
INVOLUNTARY DISENROLLMENT: Administrative action by a State to terminate a provider’s participation in the Medicaid program due to noncompliance with Medicaid rules, regulations, payment policy and/or quality of care standards.
JUDGMENT: A court’s final determination on an appeal of the rights and obligations of the parties in a case.
LIST OF EXCLUDED INDIVIDUALS AND ENTITIES (LEIE): List maintained by OIG of individuals and business excluded from participating in federally funded health care programs available at http://www.oig.hhs.gov/fraud/exclusions.html.
MANAGED CARE: A comprehensive health care delivery system that includes preventive, primary, specialty, and ancillary services. These services are provided either through a managed care organization (MCO) or primary care case management (PCCM) provider. 42 CFR Part 438.
MANAGED CARE ORGANIZATION (MCO): An organization or entity that has a comprehensive risk contract under Medicaid to provide benefits to Medicaid clients. 42 CFR Part 438
MANAGED CARE OVERSIGHT: Management and/or supervision of managed care organizations to ensure compliance with Medicaid rules, regulations, and policies.
MEDICAID FRAUD CONTROL UNITS (MFCUs): A functional entity, usually located in the offices of the State Attorney General, or other Department designated by the State that investigates and prosecutes Medicaid fraud cases and reviews complaints alleging abuse or neglect of patients in health care facilities receiving Medicaid payments. MFCUs operate under a Memorandum of Understanding with the State Medicaid Agency and are subject to oversight by the DHHS’ OIG. MFCUs must meet the requirements of 42 CFR Part 1007.
MEDICAID INTEGRITY: Planning, prevention, detection, and investigation/recovery activities undertaken to minimize or prevent overpayments due to Medicaid fraud, waste, or abuse.
MEDICAID INTEGRITY PROGRAM (MIP): A program established by the Deficit Reduction Act (DRA) of 2005 at section 1936 of the Social Security Act (Act). MIP provides the Centers for Medicare & Medicaid Services (CMS) with increased resources to prevent, identify, and recover inappropriate Medicaid payments. The two main operational responsibilities under the program are:
reviewing the actions of those furnishing items or providing services under Medicaid and providing effective support and assistance to States to combat Medicaid fraud, waste, and abuse.MEDICAID MANAGEMENT INFORMATION SYSTEM (MMIS): An automated claims processing and information retrieval system required under the Medicaid program that produces service utilization and management information.
MEDICAID RAC PROGRAM: Recovery audit contractor administered by a State to identify overpayments and underpayments and recoup overpayments. They are typically paid through contingency fee arrangements.
NATIONAL PRACTITIONER DATABANK : A computerized data bank maintained by the federal government that contains information on physicians who have paid malpractice claims or against whom certain disciplinary actions have been taken.
OFFSET: Withholding of funds from future provider payments to recover overpayments identified through Medicaid program integrity activities.
OVERPAYMENT: Any payment made to a Medicaid provider in excess of the payment to which the provider was entitled under State or federal laws and regulations.
PARTICIPANT: An individual who receives benefits under the Medicaid program.
PARTICIPATING PROVIDER: Provider that actively bills the Medicaid program.
PREDICTIVE MODEL: A mathematical or statistical method for analyzing a body of data and predicting or forecasting future results or behavior.
PREVENTION: Activities to minimize the risk of fraud, waste, or abuse entering the payment system and activities used to educate Medicaid program staff and providers.
PRIMARY CARE CASE MANAGEMENT (PCCM): The health care management activities of a provider that contracts with the State to provide primary health care services and to arrange and coordinate other preventive, specialty, and ancillary health services reimbursed on a FFS basis.
42CFR Part 438.
PRIOR AUTHORIZATION: A formal process by which, as a precondition for provider reimbursement, providers or clients must obtain approval for certain medical services, equipment, or supplies (based on medical necessity) before the services are provided to clients.
PROVIDER: Any person or entity enrolled in the Medicaid program that provides services and/or furnishes items that are billable under Medicaid.
PROVIDER EDUCATION/COMMUNICATIONS: Activities designed to educate and communicate with providers about Medicaid rules, regulations, and policies to ensure quality of care and payment integrity.
PROVIDER PAYMENT SUSPENSION: The withholding of payment by a State Medicaid Agency to a provider or supplier before a determination of the amount of the overpayment exists.
RECOVERY: Collections and offsets received from providers as a result of overpayments or other State program integrity activities. Does not include third party liability (TPL) or prior authorizations.
REFERRAL: Information on potential provider fraud that is forwarded from the State Medicaid Agency to the Medicaid Fraud Control Unit (MFCU) or other State or federal investigative Agency.
RETURN ON INVESTMENT (ROI): Savings/collections attributable to Medicaid program integrity efforts per dollar invested.
SAMPLING: Random selection of a subset of a population.
SANCTION: A penalty assessed on a Medicaid provider for a violation or violations of Medicaid laws, rules, regulations, or policies. May be in the form of a fine, suspension, termination, exclusion, civil monetary penalty, requirement for correction action, or other remedy/action.
SETTLEMENT: A negotiated agreement to collect identified overpayments from a Medicaid provider.
SINGLE STATE AGENCY (SSA): The single Agency within the State responsible for the administration of the State Medicaid plan on behalf of the State.
STANDARD OPERATING PROCEDURE: An established procedure to be followed in a given situation.
STATISTICAL ANALYSIS: Process of examining data to draw conclusions or make inferences about a population based on a sample or subset of the population.
STRATEGIC PLAN: A document used by an organization to align its policies and budget structure with organizational priorities, missions, and objectives. Should include a mission Statement, a description of the Agency’s long-term goals and objectives, and strategies or means the Agency plans to use to achieve these goals and objectives. May also identify external factors that could affect achievement of long-term goals.
SURVEILLANCE AND UTILIZATION REVIEW SUBSYSTEM (SURS): A component of the Medicaid Management Information System designed to process information on medical and health care services to assist Medicaid program managers in identifying possible fraud and abuse by providers and Medicaid clients. State SURS staffs perform data mining and other research for post-pay utilization review of providers and clients in order to identify questionable patterns of service delivery and utilization.
TERMINATED PROVIDER: A provider who has been terminated from Medicaid program participation by the State Medicaid Agency due to program integrity concerns.
THIRD PARTY LIABILITY (TPL): The term used by the Medicaid program to refer to another source of payment for covered services provided to a Medicaid beneficiary.
TIP: Complaint of suspected Medicaid provider fraud, waste or abuse.
TOTAL RECOVERIES: Dollars recovered by the State from overpayments, settlements, judgments, and other collections (excluding TPL and prior authorization).
WITHDRAWN PROVIDER: A provider who has withdrawn from participation in the Medicaid program.
The Department of Health and Senior Services, Division of Senior and Disability Services recently distributed PM-04-08 to all in-home services providers on Feb. 7, 2012. This memo is available at http://health.mo.gov/seniors/hcbs/ihsmemos.php. The memo announced the schedule of regional provider meetings being held by the Division of Senior and Disability Services.
19 CSR 15-7(14)(D) states, “all providers must…ensure the designated managers annually attend division sponsored training designed to update certified managers.” The Missouri Medicaid Audit and Compliance Unit (MMAC) has made the decision to allow attendance at one of these regional provider meetings to meet this annual training requirement.
Certified managers should maintain a copy of the agenda or handouts as proof of attendance at the meeting.
If you have any questions regarding this notice, please contact Provider Contracts via email at mmac.ihscontracts@dss.mo.gov
