HCBS PROVIDERS: AUDIT GUIDELINES

September 18, 2015

For home and community based providers, Missouri Medicaid Audit and Compliance (MMAC) wishes to provide the following audit guidelines. We hope this will assist you with preparation for an audit, and also help you properly retain adequate documentation and help you bill MO HealthNet properly, regardless of whether you are subject to an audit or not.

 

MMAC will notify you of an on-site audit prior to arrival, in most instances. Unannounced audits are rare. MMAC will accommodate your needs and schedule, within reason. We will generally provide you a partial list of participants and dates of services that are part of our review (audit.) This is so you can begin to prepare and pull records prior to our arrival. We will send this partial list to you by fax or email. We will provide the complete list upon arrival. MMAC generally needs a place for two auditors and their two laptop computers and scanners, in order to properly scan records.

 

The following items are typically the items MMAC will request and review:

The plan of care, or Web Tool print-out (or LTACS) for each participant being reviewed, within the review period Any and all documents that support services billed for each participant, for the dates of service within the review period. This may include timesheets, whether paper or EVV (telephony), or any other supporting documents Copies of the initial employee FCSR screenings, (for employees who are part of the review period) Copies of Good Cause Waiver requests and their outcomes (for employees who are part of the review period) Documentation to support billing for Authorized Nurse Visits MMAC may also request one complete participant file and one complete employee file while on-site

 

For Residential Care Facilities (RCFs):

MMAC may request service delivery logs, and/or any documents that show services provided MMAC may request census records, medication administration records, or nurse’s notes for the time period being reviewed MMAC may request evidence of employee background screening

 

As well, for quality assurance purposes, MMAC may request

Documentation for two employees or attendants which verifies initial and ongoing training requirements were met. This includes classroom training and on the job training. This also includes any training waivers and those supporting documents Verification of liability insurance and a dishonesty bond

 

For Consumer Directed Services (CDS) vendors:

A verification that the consumer was trained by the provider regarding recruiting, hiring, supervising the attendant, etc. A verification that the appropriate tax forms have been complete and are on file with the vendor

RAC Credit Balance Transfer Review-Hospitals

February 14, 2012

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.

Recovery Audit Contractor (RAC)

December 2, 2011

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.