The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain drugs. In order to collect accurate data for the rebate process, all incorrectly billed pharmacy claims must be corrected in the Medicaid billing system so accurate drugs and quantities are reported. Therefore, providers who wish to self-disclose incorrectly billed pharmacy claims to Missouri Medicaid Audit and Compliance (MMAC) are asked to not submit a check.
Instead, the claim number(s) (ICN) should be reported on the self-disclosure form along with a clear explanation of the error; MMAC staff will then correct the claim(s) in the billing system and the correction will show up as such on the corresponding Remittance Advice (RA). Click here to access the self-disclosure form. If you have any questions, please contact MMAC at mmac.providerreview@dss.mo.gov
Missouri State Regulation requires documentation of a pharmacist’s offer to counsel, for all MO HealthNet participants’ prescriptions. The regulation states, “Documentation of Offer to Counsel: The pharmacist shall document for each MO HealthNet patient’s prescription in a uniform fashion, whether the offer to counsel was accepted or refused by the patient or the patent’s agent. “ Click here to read the regulation: 13 CSR 70-20.310(7).
Additionally, pharmacies must obtain the signature of the participant or his/her representative, and the relationship of the representative to the participant. Participants living in long-term care facilities such as nursing facilities, ICF/MR facilities, and psychiatric residential treatment facilities are granted an exemption from this requirement.
The signature log serves as verification that the participant received the prescription dispensed. One signature per prescription is required, and electronic signatures are acceptable. Providers must make the signature log and offer to counsel available upon request by MO HealthNet or MMAC. More information about signature log requirements is found in the MO HealthNet Pharmacy Manual. Click here to access the manual.
Please contact Missouri Medicaid Audit and Compliance (MMAC) at MMAC.PROVIDERREVIEW@DSS.MO.GOV if you have any questions
Missouri Medicaid Audit and Compliance (MMAC) is responsible for reviewing Medicaid (MO HealthNet) participants who may be subjecting the Medicaid program to fraud, waste, and abuse due to mis-utilizing or over-utilizing some of their MO HealthNet benefits. MMAC will review the number of physicians prescribing services to a particular participant, the number of pharmacies used by the participant to obtain prescriptions, the frequency of refills or overlapping prescriptions, the number of emergency room visits, and the services received by the participant.
If a MO HealthNet participant is determined to by mis-utilizing MO HealthNet benefits, he or she can be restricted to a physician/clinic, pharmacy, or both, in accordance with 13 CSR 70-4.070. This restriction is called “Locked In”. The Lock-In program is also described in the MO HealthNet Physician Manual.
When a participant is “locked in” to a specific provider, the provider’s name and telephone number are identified on the internet, IVR, or point of service terminal used when verifying eligibility. Payment for services for a “locked-in” participant will not be made to unauthorized providers, except for emergency services, and authorized referral services. Emergency services must be supported by medical records documenting the emergency circumstances.
The designated (authorized) “lock-in” provider is responsible for the participant’s primary care and for making necessary referrals to other providers as medically indicated. When a referral is necessary, the authorized physician must complete a Medical Referral Form of Restricted Participant (PI-118) and send it to the provider to whom the participant is referred.
The referral forms are available on the MMAC website. Click here to access the forms.
The referral is good for 30 days only from the date of service. The Reason for Referral field should be completed on the form, and the form must contain the NPI (and taxonomy code if appropriate) of the authorized provider. If the participant is locked into a clinic, use the clinic’s NPI (not the individual physician’s). The form must be submitted by the unauthorized provider via the internet at www.emomed.com, or mailed to Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102.
Read more about the Participant Lock-In Program at the MMAC website.
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
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.
