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.
