Illinois Department of Children and Family Services Office of Medicaid Certification and Program Services Post Payment Review Procedures Revised July 1, 2017 Purpose The purpose of these procedures is to describe the processes by which the Department will conduct Post Payment Reviews of providers who: Are certified pursuant to the provisions of 59 Illinois Administrative Code Part 132, Medicaid Community Mental Health Services Program (Rule 132) to provide Medicaid funded community mental health services; and Have a contract with the Department to provide such services to Medicaid-eligible clients of the Department. Background The Illinois Department of Health Care and Family Services (HFS) is the state agency designated to administer Social Security Act Title XIX, Medicaid Service. Community Mental Health Services are authorized by and defined in the State s approved Medicaid State Plan. Requirements for the program are specified in Section 59 Illinois Administrative Code Part 132, Medicaid Community Mental Health Services Program (Rule 132). HFS entered into inter-agency agreements with the Illinois Departments of Human Services (DHS) and Children and Family Services (DCFS) to administer the program on behalf of HFS. Section 132.42 of Rule 132 authorizes the Department to conduct on-site post-payment reviews to determine compliance with this Part [Rule 132] and to determine amounts subject to recoupment. Recoupment is the process by which the Department recovers funds from a provider based on billings for Rule 132 services submitted for reimbursement to DCFS that are unsubstantiated (i.e., a service was either not properly authorized or not properly documented in compliance with Rule 132 requirements applicable to a specific service). The Department has a contract with the Infant-Parent Institute (IPI) to assist the Department with administration of Rule 132. Conducting Post Payment Reviews is one duty of IPI under the contract; therefore, it will be IPI staff (hereinafter referred to as PPR staff ) that will conduct Post Payment Reviews, subject to the supervision and approval of the Department. However, the Department retains the sole responsibility and authority for Post Payment Review procedures, findings, and recoupment. Frequency and Scheduling of Post Payment Reviews Any provider who scores 95% or higher on the overall unit compliance percentage will not be subject to a Post Payment Review conducted by the Department the following year, but Post Payment Reviews will resume after the one year hiatus. This determination is at the sole discretion of the Department and the Department may conduct a Post Payment Review if a provider meets any of the criteria outlined in the Additional Post Payment Review section below. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 1 of 9
Additional Post Payment Reviews Additionally, the Department may, at its sole discretion, direct that an additional Post Payment Review be completed when any of the following circumstances occur: A provider receives a compliance level rating of 3 or 4 as the result of a 12 Month Certification Review or a Three-Year Recertification Review; A provider fails to submit an acceptable Plan of Correction following a certification review as required by Part 132; Prior to processing an additional payment to a provider when prior verified payments to a provider are less than the dollar value of Rule 132 services accepted by the Department s Medicaid Billing System; and Any other time the Department has reason to believe that a provider is failing to provide Rule 132 compliant services and/or is billing for unsubstantiated services. Annual Post Payment Review A Post Payment Review will be conducted once per state fiscal year (July 1 of one year through and including June 30 of the next year) for any Part 132 certified provider with one or more contracts eligible for PPR as determined by DCFS. A schedule for Post Payment Reviews will be developed to ensure that each provider receives a Post Payment Review on an annual basis. The schedule will take into account the number of providers that must be reviewed as well as the number of staff that are available to complete the reviews. IPI will ensure that PPR staff assigned to lead the PPR, and Certification staff assigned as primary consultant to the provider will maintain separation of duties. Prior to each Post Payment Review, the staff assigned to lead the Post Payment Review will coordinate with provider staff to determine, to the extent possible, mutually agreeable date(s) and location(s) for the review. When the date(s) and location(s) are determined, the assigned PPR staff will send the provider a confirmation letter explaining the type and scope of the review. The letter will also explain that the provider will be notified one day prior to the review regarding the client records to be reviewed. The letter will ask the provider to have the entire client record available for review, including at least the previous 12 months of service documentation for each client identified for the Post Payment Review. Post Payment Review Elements Scope of Post Payment Reviews Post Payment Reviews will not be conducted within the first year after a contract has been converted to the Medicaid format. All Post Payment Reviews will be conducted using data from the Web-Based Medicaid Billing System and compliance requirements as stated in Title 59: Mental Health Chapter IV: Department of Human Services, Part 132 Medicaid Community Mental Health Services Program, in effect at the time services were delivered. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 2 of 9
Post Payment Review Staffing Post Payment Reviews will be conducted by PPR staff. The PPR staff leading the Post Payment Reviews will be either LPHAs or QMHPs. The Post Payment Review process will be separate and apart from each provider s certification review. Consultants who have lead responsibility for certification for a provider will not participate in the Post Payment Review for that provider. IPI s Associate Director of Operations and Post Payment Review Coordinator will have the overall responsibility to ensure continuity of review standards for Post Payment Reviews. Client Selection and Service Sampling The following sampling parameters will be used to determine the client records and services to be included in the Post Payment Review for each provider: The number of client records to be reviewed will be determined based on the following criteria: o For providers with a single DCFS Medicaid contract, 10 client records will be selected from that contract for review. o For providers with multiple DCFS Medicaid contracts, 10 client records will be selected for review. A minimum of one client record per contract will be reviewed, and the number of client records selected from each contract will be proportional to the level of accepted billing in each contract. o For agencies that have more than 10 DCFS Medicaid contracts, the number of records selected will be proportional to number of DCFS Medicaid contracts (e.g., 12 contracts = 12 client records reviewed). o If the provider has fewer than 10 DCFS clients served in all DCFS Medicaid contracts in the 12 months preceding the review, all DCFS clients will be selected for the review. After the number of client records to review has been identified, the specific client records to be reviewed will be selected from the client records with the highest level of accepted billing. When the clients to be reviewed have been selected, all accepted billing entries for each selected client will be identified. Within each Medicaid service type, a random selection of five (5) days of service from each billed service type will be identified for review. A maximum of 10 billing notes will be reviewed for each Medicaid service type in each client record. This service sampling can be changed at the discretion of DCFS. For providers who use electronic client record systems that include electronic signatures (as approved by DCFS), 10 random staff signature codes will be selected for a personnel review. The staff signature codes will be selected from Medicaid billing notes. The personnel records for the randomly selected staff signature codes will be examined to determine compliance with 132.85f). Post Payment Review staff will notify a provider of the clients to be reviewed one (1) working day before the scheduled date for the Post Payment Review. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 3 of 9
Review Elements The following documentation elements will be included as part of the review of each billing record (as each element is applicable to an individual service being reviewed): 132.30f)1) Provider certified for service 132.145b) & 132.148a)1) - Service properly authorized/medical necessity established by Admission Note, MHA and/or ITP. 132.100i) - Legibility of service note 132.100i)1) - Corresponding note in the client record 132.100i)2) - Date of service 132.100i)3) - Start time of service 132.100i)3) - Duration of service 132.100i)4) - Staff signature 132.100i)4) - Staff credential 132.100i)5) - Specific on/off site location 132.148, 132.150 & 132.165 - Service definition Post Payment Review Forms The forms used during Post Payment Reviews will allow PPR staff to clearly identify and document the reasons for unsubstantiated billings (e.g., service not recommended on the ITP, provider not certified to provide the service, ITP not in effect on the date the service was provided). A Client Record Review Face Sheet will be used during Post Payment Reviews to record relevant client record information including: Medicaid services for which the provider is certified; Completion date of and Medicaid services listed on the ITP; Completion date of and Medicaid services listed on the ITP Review(s), if applicable; Completion date of and Medicaid services listed on the Admission Note, if applicable; and Completion date of and Medicaid services listed on the Mental Health Assessment, if applicable. A Service Documentation Worksheet will be utilized to document if billings are fully compliant with the requirements of Rule 132 applicable to the service being reviewed or, conversely, are unsubstantiated. The Worksheet includes prompts for the following Rule 132 requirements to be evaluated for each service note reviewed: 132.30f)1) - Provider certified for service 132.145b) & 132.148a)1) - Service properly authorized/medical necessity established by Admission Note, MHA and/or ITP. 132.100i) - Legibility of service note 132.100i)1) - Corresponding note in the client record 132.100i)2) - Date of service 132.100i)3) - Start time of service DCFS Medicaid Rule 132 Post Payment Review Procedures Page 4 of 9
132.100i)3) - Duration of service 132.100i)4) - Staff signature 132.100i)4) - Staff credential 132.100i)5) - Specific on/off site location 132.148, 132.150 & 132.165 - Service definition Dollar amount of service submitted to Web-based Medicaid Billing System Entrance Conference An entrance conference with the provider staff will be conducted to explain the type and scope of the review and to answer any questions provider staff may have about the review. At a minimum, a provider must designate one or more staff to assist PPR review staff with any questions and/or logistical issues that may arise during the review. Review of Records and Billings Following the entrance conference, PPR staff will review selected Medicaid services for compliance with all Rule 132 requirements using the Service Documentation Worksheet. Findings of non-compliance with any of the requirements listed above will be recorded on the Service Documentation Worksheet that specifically indicates the Rule 132 requirement with which the service did not comply. The information will be used in identifying unsubstantiated billings for inclusion in the Notice of Unsubstantiated Billings (NUB). If PPR staff are unable to locate documentation, they will request assistance from the provider staff to locate the missing documentation. For missing authorizing documents (e.g., MHA, ITP), the reviewers will immediately notify the provider. For missing service documentation, the reviewers will notify the provider at the completion of each record. Provider staff will be given until one hour after the last client record has been reviewed to locate the missing service documentation. If the documentation cannot be located within one hour of the completion of the last client record, the PPR staff will indicate that specific billing entry as unsubstantiated due to missing supporting documentation. After completing the review of all records and billings, PPR staff will develop a preliminary list of findings, including a preliminary dollar amount related to unsubstantiated billings that may be eligible for recoupment by the Department. Exit Conference Prior to leaving the provider location, PPR staff will conduct an exit conference with the provider staff. The purpose of the exit conference is to review the type and scope of the review and to provide a detailed explanation of the review findings, including but not limited to the preliminary dollar amount eligible for recoupment due to unsubstantiated billings. Provider staff will have time to ask questions about the findings and the next steps of the Post Payment Review process. PPR staff will outline and explain the specific follow up steps and the associated time frames for completion of these activities. Post Payment Review staff will also inform the provider that a Notice of Unsubstantiated Billings (NUB) will be sent to the provider from the Department within 30 calendar days. Post Payment Review staff also will inform the provider of the process for filing an appeal. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 5 of 9
The Department may, at its sole discretion, request review of an expanded number of billings based on a report of preliminary findings. If during the Post Payment Review, PPR staff finds evidence of suspected Medicaid fraud or abuse, DCFS will refer such evidence to HFS, Office of Inspector General for further action. Please note: For any unsubstantiated billings noted as missing, PPR staff will verify whether any voids or adjustments were made to the cited units. Only modifications made prior to the provider notification of the specific clients included in the review will be removed from the PPR results. Report Part 132.42 requires that within 30 days a Notice of Unsubstantiated Billings (NUB) be issued to notify providers regarding the findings from Post Payment Reviews. The NUB will include a cover sheet with all necessary provider information (e.g., name, address, contact person, contract reviewed, date of review, review participants, etc.). The NUB will also include a short explanation of the review that was conducted, a numbered list of the client records, dates, specific service types, and dollar amounts of services that were found to be unsubstantiated. An explanation of the reason(s) each service was unsubstantiated (e.g., service not recommended on the ITP, provider not certified to provide the service, ITP not in effect on the date the service was provided) will also be included. The final section of each report will identify the total dollar amount of unsubstantiated billing found during the review. The NUB will include the final dollar amount identified for recoupment and will also include information about the provider s right to appeal. Performance Improvement Plan If any units of service reviewed are found to be unsubstantiated, the provider will be required to complete a Performance Improvement Plan (PIP) that will address correction of any Post Payment Review elements identified as non-complaint during the review. The provider will be given a copy of the Post Payment Review Performance Improvement Plan Guidelines to assist them in the development of the PIP. The PIP is due to DCFS 30 days after the receipt of the NUB. If the PIP does not sufficiently address all areas that were identified as unsubstantiated in the NUB, the PIP will be will be sent back to the provider for revision. Notice of Suspension from Billing If more than 50% of the units of service reviewed are found to be unsubstantiated, the provider will receive a Notice of Suspension from Billing (NOSB) within 30 days after the review. The Suspension from Billing will include all Part 132 services. The provider is required to immediately stop submitting bills upon receipt of the NOSB. The provider will have 60 days to make corrections to its documentation processes to bring them into compliance. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 6 of 9
When the necessary corrections have been made the provider will notify DCFS in writing. The Performance Improvement Plan may be used to document corrections that have been implemented. DCFS will have 14 days to review the corrections for compliance. If corrections have been made, DCFS will notify the provider in writing that the suspension will be lifted, and the provider will be allowed to bill for compliant services provided during the suspension period. If the provider does not adequately address changes made to its documentation processes, further documentation of corrections will be requested. If corrections are not made within 60 days, DCFS shall revoke the provider s certification. DCFS reserves the right to conduct follow up on-site reviews to verify implementation of corrective actions related to billing suspension at its sole discretion. Recoupment Procedures Each billing entry selected will be reviewed to determine if a corresponding service note exists that is compliant with all of the above mentioned Rule 132 requirements, as applicable. Each service note that complies with all of the above mentioned Rule 132 requirements, as applicable, will be considered compliant. No recoupment of funds will be required for compliant service notes. If a billing entry does not have a corresponding service note or if the corresponding service note is non-compliant with one or more of the above mentioned Rule 132 requirements, as applicable, the units of service identified in that billing entry will be eligible for recoupment by DCFS. Correction of service notes will not be allowed following the Post Payment Review. The amount of recoupment will equal the rate for each service that was unsubstantiated multiplied by the number of units of that service. Void/Adjust Process After the timeline for appeal has passed or after the final determination of the appeal process outlined in Rule 132.44, all unsubstantiated billings must be VOIDED or ADJUSTED in the Web-based Medicaid Billing System, as indicated in the NUB. The Department will notify providers of the specific timeframes to start and complete VOIDS or ADJUSTS to unsubstantiated claims related to the Post Payment Review. If a billing has previously been adjusted, the provider will need to contact PPR staff for assistance. Any unsubstantiated billings that are not VOIDED or ADJUSTED in the Web-based Medicaid Billing System will become the sole responsibility of the provider. Recoupment Process Recoupment related to unsubstantiated billings identified during a PPR, including unsubstantiated billings identified through an expanded review, will be handled on a contract-by-contract basis, as follows: For Medicaid Agency Counseling and Medicaid Post Adoption contracts, unsubstantiated billings must be voided or adjusted as part of the recoupment process. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 7 of 9
For services reviewed under the Medicaid Rate Carveout (MRC) contracts, unsubstantiated billings must be voided or adjusted as part of the recoupment process. Appeal Process Section 132.44 includes the following elements related to provider s ability to appeal the findings of a Post Payment Review: a) If the State agency determines that the provider is not in compliance with the requirements of this Part pursuant to a post-payment review conducted in accordance with Section 132.42, the State agency shall notify the provider in writing of its findings. The notice shall include: 1) The reason for the State agency's findings; 2) A statement of the provider's right to request a hearing within 20 days after the provider's receipt of the written notice; 3) A statement of the legal authority and jurisdiction under which the hearing is to be held; and 4) The address where a request for hearing may be filed. b) If a provider chooses to appeal the State agency's findings, the provider shall submit a written request for a hearing to the State agency within 20 days after the date of receipt of the written notice. c) The sole issue at the hearing shall be whether the provider is in compliance with requirements set forth in this Part. d) The request for hearing shall be filed with, and received by, the State agency within 20 days after the date of the receipt of the written notice to the provider. e) Hearing process 1) HFS's hearing rules for medical vendor hearings at 89 Ill. Adm. Code 104.200 shall apply, except that the following Sections do not apply to these hearings: 104.204, 104.206, 104.208, 104.210, 104.216, 104.217, 104.221, 104.260, 104.272, 104.273 and 104.274. 2) The State agency shall, within 5 days after receiving the appeal, send a copy of the appeal to the Illinois Department of Healthcare and Family Services Vendor Hearings Section, 401 South Clinton, 6 th Floor, Chicago, Illinois 60607. 3) The appellant shall direct all subsequent communications relevant to the hearing to the HFS Vendor Hearings Section. 4) An administrative law judge appointed by HFS shall conduct the hearing. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 8 of 9
5) A recommended decision shall be submitted to the Director of Healthcare and Family Services and copies mailed to the parties, in accordance with the provisions of 89 Ill. Adm. Code 104.290. A copy shall also be mailed to the State agency that referred the matter to HFS. f) Final administrative decision The Director of Healthcare and Family Services shall issue a final administrative decision in accordance with the provisions of 89 Ill. Adm. Code 104.295. g) Judicial review The final administrative decision shall be subject to judicial review exclusively as provided in the Administrative Review Law [735 ILCS 5/Art. III]. h) A provider shall be liable for reimbursement of claims submitted from the date of the final administrative decision pursuant to this Section if such decision results in an adverse finding for the provider. Follow-Up Ongoing question and answers For Post Payment Reviews conducted after July 1, 2012, DCFS along with IPI will develop a Post Payment Review Frequently Asked Questions (FAQ) page that will be posted on IPI s website. The purpose of the FAQ will be to ensure that providers receive uniform answers to questions related to the Post Payment Review process. Providers who have questions related to Post Payment Review that are not included in the FAQ will be able to contact the PPR staff to receive an answer to their question. DCFS Medicaid Rule 132 Post Payment Review Procedures Page 9 of 9