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.