Credit balances on patient accounts occur for a variety of reasons.  For instance, providers sometimes receive duplicate payments, charges may be reversed, billing data may be incomplete, and third party liabilities may be incorrectly applied.  Providers routinely identify and refund these credit balances (overpayments), but sometimes the ability to refund the overpayment in a timely fashion is constrained by limited resources or imperfect information.  Sometimes, providers aren’t aware the overpayments exist.  Not all credit balances result in an overpayment, and out of those, not all require a refund; some simply require an adjustment.

HMS will soon begin conducting credit balance audits, on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and Missouri Medicaid Audit and Compliance (MMAC).  When your hospital or nursing home is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS.  MMAC will also notify the Missouri Hospital Association, Missouri Health Care Association, and LeadingAge Missouri.

Nursing home audits will be conducted as “desk audits”.  This means that HMS will review the patient accounts off-site after receiving any necessary documentation from the nursing home.  These audits will be specific to Medicaid patients (participants.)

Hospital audits will be Medicaid-specific, as well.  Hospital audits may be desk audits, or they may be completed on-site.

Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.