The Centers for Medicare and Medicaid Services issued State Medicaid Director Letter #09-001 dated January 16, 2009 regarding excluded persons. The letter advises States of their obligation to direct providers to screen their employees and contractors for excluded persons. In particular, the letter states, in part:
Policy Clarification: States Should Advise Medicaid Providers to Screen for ExclusionsTo further protect against payments for items and services furnished or ordered by excluded parties, States should advise all current providers and providers applying to participate in the Medicaid program to take the following steps to determine whether their employees and contractors are excluded individuals or entities:
States should advise providers of their obligation to screen all employees and contractors to determine whether any of them have been excluded. States should communicate this obligation to providers upon enrollment and reenrollment.
States should explicitly require providers to agree to comply with this obligation as a condition of enrollment.
States should inform providers that they can search the HHS-OIG website by the names of any individual or entity.
States should require providers to search the HHS-OIG website monthly to capture exclusions and reinstatements that have occurred since the last search.
States should require that providers immediately report to them any exclusion information discovered.
The letter can be viewed in its entirety at:
https://www.cms.gov/SMDL/downloads/SMD011609.pdf
The Missouri Medicaid Audit and Compliance Unit does consider compliance with the steps outlined in the letter and summarized above as an integral part of a providers’ provision of service delivery to MO HealthNet program participants. Compliance with these requirements may be subject to review by the Missouri Medicaid Audit and Compliance Unit.
The Missouri Medicaid Audit & Compliance Unit (MMAC) issues final decision letters to providers after conducting reviews of post-payment claims. Providers must be aware that the overpayment amount detailed in their final decision (demand) letter is a sanction according to 13CSR 70-3.030. Providers are prohibited from submitting on-line claim adjustments for erroneous payment to correct the overpayment. Providers must submit payment to MMAC Unit via check or electronic transfer from future remittance advice.
Questions and concerns regarding repayment can be directed to the MO HealthNet Division Provider Education Unit representative.
MMAC enforces this sanction per authority of 13 CSR 70-3.030.
The Centers for Medicare & Medicaid Services (CMS) is hosting six Payment Error Rate Measurement (PERM) program provider education webinar/conferences calls during PERM Cycle 1 (2012) of which Missouri is included. The purpose is to provide an opportunity for the providers of the Medicaid and Children’s Health Insurance Program (CHIP) communities to enhance your understanding of specific provider responsibilities during PERM.
The PERM program is designed to measure improper payments in the Medicaid and CHIP programs as required by the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act (IPERA). Webinar/Conference call participants will learn from presentations that feature:
The PERM process and provider responsibilities during a PERM review Frequent mistakes and best practices The Electronic Submission of Medical Documentation (esMD) programParticipant call in information will be posted on the Provider Education Calls link: http://www.cms.gov/Research‐Statistics‐Data‐and‐Systems/Monitoring‐ Programs/Perm/Provider_Education_Calls.html approximately 10 days prior to the calls.
The PERM Cycle 1 (2012) Provider Education Webinar/Conference calls Webinar links are being presented on a Connect Pro platform. To test your connect launch: https://webinar.cms.hhs.gov/common/help/en/support/meeting_test.htm
The webinar dates are:
May 23, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web1
To join the meeting: https://webinar.cms.hhs.gov/perm1web1/
June 21, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web2
To join the meeting: https://webinar.cms.hhs.gov/perm1web2/
July 24, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web3
To join the meeting: https://webinar.cms.hhs.gov/perm1web3/
August 23, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web4
To join the meeting: https://webinar.cms.hhs.gov/perm1web4/
September 25, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web5
To join the meeting: https://webinar.cms.hhs.gov/perm1web5/
October 24, 2012 1:00 to 2:00 PERM Cycle 1‐2012‐Web6
To join the meeting: https://webinar.cms.hhs.gov/perm1web6/
There will be time available for questions and answers at the end of the presentations however; CMS encourages all participants to submit questions in advance to our designated PERM Provider email PERMProviders@cms.hhs.gov or you may also contact your State PERM representative, Carissa Duewell, at MMAC Carissa.duewell@dss.mo.gov or 573/751‐3399 with any questions and for education and training in your state.
Please check the CMS Website and PERM Provider’s page regularly for helpful education materials, FAQS, and updates at http://www.cms.gov/PERM/.
Claims have incorrectly paid for dentures/partials for adults with a limited benefits package. Dentures/partials of any kind are not a covered service for adults with a limited benefits package. Please reference the MO HealthNet Dental Manual, Sections 19.1.G(1) and (2), which states,” dentures/partials are coverable for children under 21 or for persons under a category of assistance for pregnant women, the blind or vendor nursing facility residents.”
Due to the incorrect payment of these claims, a mass adjustment will be initiated in the near future to correct this error. Please check all future remittance advices for the specific claims that were mass adjusted. In addition, we are requesting that you perform a self-audit to identify any incorrectly paid claims for dentures/partials for adults with a limited benefits package that may have paid during or after the mass adjustment process.
Missouri awarded its Recovery Audit Contractor (RAC) Contract to Cognosante, LLC. Under the purview of Cognosante, LLC, Arbor Healthcare has been contracted to perform Credit Balance Transfer Audit services for this contract. The Credit Balance audit process involves reviewing the financial payments made to patient accounts to ascertain the accuracy of the State’s reimbursement from the actual claims issued. Reviews/audits will not be conducted for third party liability (TPL) balances residing on patient accounts. The reviews/audits will focus on Medicare duplication of payments or other erroneous errors that do not pertain to TPL that may warrant a credit balance.
Arbor Healthcare’s approach to credit balance reviews begins with the Provider Relations staff (PRMs) communicating with the hospitals to schedule onsite audit visits at the billing office locations. The PRMs maintain communications with the hospital directors to ensure continued access to the facility and to enhance or expand the volume of days per month which the Arbor audit staff are allowed to visit the individual hospital facilities. Utilizing the state’s 1099 reports, Arbor Health will identify hospitals that generate significant Medicaid claims and should be candidates for credit balance reviews. Arbor Healthcare will work with the state to determine the hospitals to audit and frequency of on-site audits.
The actual Credit Balance audit phase begins by having an onsite field analyst visit each assigned provider location, allowing the analyst access to the providers’ complete payment record of each claim, and enabling the analyst to accurately resolve the errors, optimizing recoveries for Missouri Medicaid, and minimizing processing time and costs for payers and providers.
Arbor Healthcare then prepares review documentation that is presented to the Provider at the conclusion of the audit day, which documents the proper actions necessary to resolve the Credit Balance on the particular accounts reviewed by Arbor Healthcare. This review documentation includes “Refund Request” letters for any overpayment refunds that were identified. The Provider reviews the audit findings and has the ability to question the findings prior to the exit of Arbor from the facility.
The State has the ability to review all backup and claim calculations to determine its agreement with the refund rational, as well as the calculated refund value. The State will be able to signify its Approval/Denial via online selection or through downloading of Microsoft- based export files.
Please note that Missouri has decided to participate in the Medicare-Medicaid Data Match
Program.
The Centers for Medicare and Medicaid Services (CMS) created the Medicare-Medicaid Data Match Program, or Medi-Medi project, in 2001. This integrity program initially began in California to detect and prevent Medicaid fraud and abuse. The program expanded to other
states, and with the passage of the Deficient Reduction Act of 2005, funding increased to roll out the program nationwide.
Detecting Improper Billing and Utilization PatternsFederal regulations require that each state Medicaid agency maintain a claims processing and information retrieval system (the Medicaid Management Information System). The Surveillance and Utilization Review Subsystem, a mandatory component of the Medicaid Management Information System, exists to safeguard against inappropriate payments for Medicaid services. Patterns of fraudulent, abusive, unnecessary, or inappropriate utilization can be detected by analyzing and evaluating provider service utilization.
According to section 6034 of the Deficit Reduction Act, the Medi-Medi program is to use computer algorithms to search for payment anomalies. The abnormalities being sought include billing or billing patterns identified with respect to service, time, or patient that appear to be suspect or otherwise implausible. This data-oriented approach to mining combines Medicare and Medicaid claims to detect improper billings and utilization patterns and will enhance the ability to find vulnerabilities in both programs.
The Patient Protection and Affordable Care Act (PPACA) is a United States federal statute which was signed into law on March 23, 2010.
Section 6411 of PPACA expands to Medicaid the Recovery Audit Contractor (RAC) program, which previously applied only to Medicare Parts A and B.
The RAC reviews provider claims for covered items and services to identify potential payment errors, such as duplicate payments, mistakes by fiscal intermediaries, and incorrect coding. The audits include reviews of medical records to determine medical necessity and to identify coding errors.
RACs receive a percentage of the improper overpayments they collect and a payment for any underpayments identified.
Missouri Medicaid Audit and Compliance Unit is pleased to announce that Cognosante LLC has been awarded a contract to perform RAC services for the State of Missouri.
