Cognosante, LLC is the RAC for Missouri. 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.
Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or Cognosante, 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.
In 2015, the RAC will finish its work on outstanding pharmacy and durable medical equipment (DME) audits, and will begin conducting audits of hospital billing submitted by enrolled Missouri hospital providers. The RAC may request documentation to support billing of outpatient encounters, including professional and facility services. The RAC will review paid claims for proper billing of both professional and facility services, and the appropriate utilization of facility resources, such as supplies and facility charges. Documentation requests may include requests for itemized statements, medical records, medication administration records, radiology interpretations, and laboratory results to support the claims submitted for payment.
The RAC will begin issuing medical records requests to those hospitals selected for audit beginning July 2015.
Brown Smith Wallace LLC, Missouri’s EHR Audit Contractor
As part of the ongoing program to monitor MO HealthNet’s Electronic Health Record (EHR) Incentive Program payments, the Missouri Department of Social Services has contracted with Brown Smith Wallace LLC to conduct reviews of payments made to participating hospitals and professionals for program year 2013.
Federal regulation 495.368 requires States to comply with Federal requirements to combat fraud and abuse. Brown Smith Wallace LLC is authorized to conduct post-payment audits through desk and/or on-site reviews. Selected hospitals and professionals will receive a letter of notification indicating that they have been chosen for a review.
The purpose of the audit is to validate certain information utilized as the basis for dispersing an incentive payment, including information used in eligibility determinations and hospital payment calculations. Section 1903(t)(2) of the HITECH Act states that all Eligible Professionals and Hospitals need to meet certain patient volume thresholds in order to be eligible for Electronic Health Record incentive payments.
Information Required of Eligible Professionals and Hospitals
The following information may be required from eligible professionals and hospitals. A tip sheet with more detailed descriptions is referenced in the last bullet under each heading below.
Eligible Professionals:
Detailed encounter listing to support the numerator and denominator utilized in the eligibility calculation, Documentation to support an eligible professional’s affiliation with locations for which patient encounter volume was reported, Documentation to support an eligible professional’s affiliation with a group practice when that eligible professional utilized the group proxy to report encounter volume, and When appropriate, documentation to confirm the provider or provider organization had a legal or financial obligation to the Certified Electronic Health Record Technology at the time of A/I/U (Adopt, Implement, or Upgrade) attestation. A tip sheet for eligible professional: https://dss.mo.gov/mhd/ehr/pdf/post-payment-review-tips-eligible-professional.pdf
Eligible Hospitals:
Detailed encounter listing to support the numerator and denominator utilized in the eligibility calculation, Documentation to support discharges according to the applicable cost reports or other documentation utilized in calculating the growth rate and discharge-related amount, Documentation to support the Acute Medicaid Days, Acute Medicaid HMO days, and Total Acute days utilized in calculating the Medicaid share, Documentation to support Charity Care Charges and Total Hospital Charges utilized in calculating the Medicaid share, and When appropriate, documentation to confirm the hospital had a legal or financial obligation to the Certified Electronic Health Record Technology at the time of A/I/U (Adopt, Implement, or Upgrade) attestation. A tip sheet for eligible hospitals: https://dss.mo.gov/mhd/ehr/pdf/post-payment-review-tips-eligible-hospitals.pdfMissouri Medicaid Audit & Compliance (MMAC) has begun implementing new provider enrollment procedures including provider revalidation. Any provider whose address has changed since initial enrollment should submit the updated information to MMAC by downloading the “Provider Update Request” form at https://mmac.mo.gov/providers/provider-enrollment/new-providers/provider-enrollment-forms/. The completed forms can be scanned and sent by e-mail to mmac.providerenrollment@dss.mo.gov or they can be faxed to the Provider Enrollment Unit at (573) 751-5065.
Be sure to check MMAC’s website regularly to get information on upcoming changes and other helpful tips for MO HealthNet providers.
State and federal regulations require all currently enrolled Medicaid providers to revalidate their enrollment at least every five (5) years. MMAC has established a revalidation schedule for all currently enrolled providers. MMAC will contact currently enrolled providers approximately 120 days prior to their scheduled revalidation due date. Instructions and forms will be provided by mail or e-mail. More information on revalidation is available under the Providers tab here on our website. Under the Providers tab, choose Provider Enrollment, and Revalidating Providers.
All MO HealthNet providers are required by state regulations to disclose certain information to Missouri Medicaid Audit & Compliance (MMAC) during their initial enrollment or revalidation processes. Those mandatory disclosures include:
The name, address, date of birth, social security number, or other tax identification number of any person with a five percent (5%) or more ownership or control interest in the applying provider and any subcontractors in which the applying provider has a five percent (5%) or more interest; Whether any person with an ownership interest in the applying provider is related to another person with ownership or control interest in the applying provider as a spouse, parent, child, or sibling; Whether any person with an ownership or control interest in any subcontractor in which the applying provider has a five percent (5%) or more interest is related to another person with ownership or control interest in the applying provider as a spouse, parent, child or sibling. The name, address, date of birth and social security number of any managing employee of the applying provider.
Disclosures must be updated within thirty-five (35) days of any changes in information required to be disclosed.
MMAC is required to collect the disclosed information to screen individuals and legal entities with ownership and control interest against various state and federal exclusion databases.
Please review 13 CSR 65-2.020 for more information or email MMAC.ProviderEnrollment@dss.mo.gov if you have questions.
MMAC utilizes MO HealthNet (MHD) provider hot-tips and provider bulletins to keep providers informed about its activities. MMAC website updates will be sent to MHD in the form of hot-tips or bulletins for providers. We encourage providers to sign up for MO HealthNet News.
Provider Update Training is scheduled for April 21, 22, and 23, 2015. This Provider Update Training is for Home and Community Based Services Providers. Please open this notification and click on the link for additional information.
