Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require ordering, prescribing or referring (OPR) providers to enroll with Medicaid, even if they do not accept Medicaid. In response, MO HealthNet has begun implementing changes in the claims processing system to deny all claims that require an order, prescription or referral from a physician or other licensed health care professional unless that physician or provider has an active enrollment record on file.
The Mo Healthnet Remittance Advices for Pharmacy, Durable Medical Equipment (DME), Independent Laboratory medical claims, Imaging medical claims, and Home Health claims contain the following alert when the ordering, prescribing, or referring provider on the claim is not an actively enrolled provider:
N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.
In the future, the alert will appear on all institutional claims. Afterward, the claims processing system will begin to deny the affected claims. In order to ensure that future claims are not denied, the ordering, prescribing, or referring providers must be enrolled with MO HealthNet. In order to ease this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an
Ordering, Prescribing, and Referring (OPR) Provider Application. MMAC’s provider enrollment personnel will expedite all OPR applications received.
If you have any questions please contact MMAC.ProviderEnrollment@dss.mo.gov
In February, 2016, the Missouri Medicaid Audit and Compliance Unit (MMAC) posted a prescription fraud alert on its website. Click here to view the full post.
Some of these fraudulent prescriptions are still being presented to Missouri pharmacies. If your pharmacy is presented with a fraudulent prescription, please call your local law enforcement agency. If the fraudulent transaction involves a Medicaid participant, please continue to contact MMAC in addition to your local law enforcement agency.
Contact MMAC at MMAC.Lockin@dss.mo.us with any questions or concerns.
Extended Women’s Health Services cover family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services. They are covered by MO HealthNet for uninsured women who are 18-55 years of age with a Modified Adjusted Gross Income for the household size that does not exceed 201% of the Federal Poverty Level (FPL). The Medicaid Eligibility (ME) Code is “80/89”.
House Bill No. 2011, 2016 Regular Session, is the appropriations bill for the Missouri Department of Social Services for State Fiscal Year 2017. Section 11.550 of HB2011 is specific to Extended Women’s Health Services, and prohibits the disbursement of any funds, directly or indirectly, to subsidize abortion services or procedures or administrative functions, and also prohibits the use of any funds to pay an organization that provides abortion services. Qualified organizations, however, shall not be disqualified from receiving funds because of an affiliation with an organization that provides abortion services as long as the two organizations are independent of one another. The bill states that the independent affiliate providing the abortion services must be separately incorporated from any organization receiving these funds.
Missouri Medicaid Audit and Compliance (MMAC) is notifying all providers that may potentially be affected by this restriction. Providers will be notified via e-mail addresses that are on file with MMAC as well as by US Mail.
Organizations that are equipped to provide abortion services will be provided with an attestation that allows them to indicate they do not provide abortion services, if they do not. The organization will attest on behalf of any affiliated providers who submit 80/89 claims, if applicable. The attestation may be returned to DSS in order to ensure no interruption in claims processing for 80/89 claims. Affiliated organizations will also receive an informational letter so they are aware of the restriction and its potential impact on their reimbursement for 80/89 claims. This change does not affect any other Medicaid funding.
Please contact MMAC at MMAC.ProviderEnrollment@dss.mo.gov
As reported in a previous gov.delivery message by Missouri Medicaid Audit and Compliance (MMAC), HMS will soon begin conducting credit balance audits on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and MMAC. Click here to view the original message and website post.
When your hospital 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. Hospitals can expect to begin receiving letters regarding the credit balance audits after May 1, 2016.
Hospital audits will be Medicaid-specific, and may be desk audits, where HMS will request that you send them information; or, the audits 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.
HMS has prepared its initial schedule for hospital credit balance audits. Click here to view the schedule.
If you have any questions, please contact MMAC at tricia.smith@dss.mo.gov
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.
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.
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.pdfThe Missouri Medicaid Audit & Compliance (MMAC) Provider Enrollment Unit (PEU) has processed several applications for enrolling Physician Assistants. PEU personnel assign provider numbers and create the appropriate electronic accounts, permitting the new providers to begin submitting claims for health care services provided to Medicaid participants. At this time, MO HealthNet Division and its fiscal agent are still completing required system work to enroll and reimburse Physician Assistants.
Once MMAC receives notification that the system work is complete, PEU personnel will assign the provider number and finalize creation of the enrollment records. MMAC will backdate the effective date of the new Medicaid provider enrollments to the date the applications were originally received. In the meantime, providers can continue getting reimbursed under their current billing arrangements, or they can hold their claims until their provider numbers have been assigned. MO HealthNet permits providers to file claims for reimbursement up to one year after the services were actually provided.
Effective August 28, 2014, licensed Physician Assistants will be able to submit enrollment applications to become Medicaid providers. These applications will not be immediately processed.
Until the necessary work is completed for the Physician Assistants applications to be processed and the enrollment to actually take place, Physician Assistants may still provide services and bill under their collaborating physician’s number.
The instructions and application forms are available on this web site in PDF format under the “Provider Enrollment Applications and Forms” tab. Applicants should print out the application forms and mail them to the MMAC Provider Enrollment Unit after they are completed, along with the required documentation listed on the forms.
Per 13 CSR 70-3.020, MMAC will notify providers within 60 days of receipt of their applications when it appears the applications will not be processed within 90 days of receipt. At this time, MMAC believes that MMAC and MO HealthNet will be able to process these applications and enroll the Physician Assistants by the end of the first quarter of 2015. At that time, MMAC will begin accepting these applications in electronic format.
