Medicaid providers have expressed concern to Missouri Medicaid Audit and Compliance (MMAC) about accessing their Electronic Health Records (EHR) during an audit. Some providers have been unfamiliar with the process to access the records due to having a newly acquired EHR system.
Per state regulation, providers may maintain records in an electronic medium, and paper records may be transferred to an electronic medium, as well, as long as all information contained in the original record, including signatures, handwritten notations, or pictures, is contained in the durable medium. Records may be retained in any form that can be made available for review at the same site at which the service was provided or at the provider’s address of record with the Department of Social Services.
Copies of records must be provided upon request regardless of the media in which they are kept. Providers are encouraged to be familiar with their EHR systems and know how to produce the records upon request. Electronic records do not need to be printed off in paper form for MMAC during an audit; electronic form is preferable. MMAC auditors will accept the records in electronic form on a CD, DVD, or portable drive.
Missouri Medicaid Audit and Compliance (MMAC) has seen a recent increase in fraudulent prescriptions passed across Missouri. The prescriptions contain similarities, listed below, and illustrated in a sample template.
(click here to view the template)
Common characteristics of the fraudulent prescriptions:
St. Louis area prescribers Prescriptions are usually written for Oxycodone-Acetaminophen 10-325 for quantities of 120-180 tablets Patient addresses are invalid. The invalid street addresses are usually in the same city as the pharmacy where the prescriptions are presented Prescriptions usually presented to the pharmacy after the doctors’ offices have closed Some were presented on tamper-resistant paper.
Unless an exception exists, MO HealthNet prescriptions must be written on tamper-resistant paper. (Exceptions include prescriptions reimbursed by a MO HealthNet managed care entity, prescriptions provided in certain facilities such as nursing facilities and hospitals, and prescriptions faxed, telephoned, or e-prescribed.) As a reminder, to be compliant with this requirement, a prescription pad must contain the following characteristics:
An industry-recognized feature designed to prevent unauthorized copying of a completed or blank prescription form (such as a high security watermark on the reverse of the blank or the use of thermochromic ink) An industry-recognized feature designed to prevent erasure or modification of information written on the prescription by the prescriber (such as tamper-resistant background ink that shows erasures or attempts to change written information) An industry-recognized feature designed to prevent the use of counterfeit prescription forms (such as sequentially numbered blanks or duplicate or triplicate blanks)As noted above, some of the fraudulent prescriptions were presented on tamper-resistant paper, , highlighting the need to check for all three required features.If you suspect prescription fraud regarding a Medicaid participant, please contact MMAC.LOCKIN@dss.mo.gov or call (573) 751-3399). As well, if you suspect any person is breaking the law in your pharmacy, contact local law enforcement.
If you have any questions, please contact MMAC at MMAC.REPORTFRAUD@dss.mo.gov
Missouri Medicaid Audit and Compliance (MMAC) receives questions from Medicaid providers about our audit procedures. Click here to view audit information and guidance. The audit information and guidance covers commonly used terms, important information found in state regulation, and MMAC audit procedures.
Providers submitting claims for laboratory services and durable medical equipment (“DME”) have been receiving an alert on their remittance advices when the Ordering, Prescribing, or Referring (“OPR”) physician is not enrolled and in an active status. Currently those claims are set to pay, but in the future, the claims will not be paid until the OPR physician either enrolls or updates his or her enrollment record.
Soon providers will receive a similar alert for pharmacy claims, imaging claims, and home health claims. These also require “OPR” physician information. In the future, these claims will deny as well if the OPR physician is not enrolled. Claims will continue to pay for a period of time in order to alert providers submitting these claims.
MMAC will give priority to any OPR application we receive in order to help ensure no disruption in services or payment.
Visit mmac.mo.gov to read more about OPR requirements. Click here.
The Missouri Medicaid Audit and Compliance Unit (MMAC) has received questions from providers whose agencies provide certain types of services under the Department of Mental Health DD Waiver program. Specifically, providers of day habilitation services have requested clarification regarding adequate documentation as it pertains to participants’ progress notes.
Missouri regulation states adequate documentation is “documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty.” The regulation states adequate documentation includes “The MO HealthNet participant’s progress toward the goals stated in the treatment plan (progress notes).”
To read the regulation (13 CSR 70-3.030) click here.
MMAC auditors should be able to discern the participant, caregiver, types of services provided, date of service, and length of service, from the progress notes. The progress notes should articulate the participant’s progress toward the goals in his or her treatment plan. MMAC auditors will review these documents, along with others, to determine that services were billed for the correct participant on the correct date of service, for the correct amount of time. They will review the notes to ensure they contain information about the participant’s progress toward the treatment plan goals.
On December 2, 2015, the Department of Mental Health issued a bulletin regarding this subject. Click here to read the bulletin. This bulletin provides additional guidance regarding best practices in progress note documentation.
MMAC is committed to working together with Medicaid providers and the Department of Mental Health, regarding continuing clarification on these matters. If you have any questions, please contact us at MMAC.Providerreview.dss.mo.gov
