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/.—
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.
