MDCH Office of Health Services Inspector General Recovery Audit Contract (RAC) Provider Outreach & Education Spring 2014
Background Recovery Audit Contractor Medicare Modernization Act of 2003 created a demonstration project to identify Medicare overpayments The program was operational from 2005 through 2007 Following success of the demonstration project, the program was made permanent in 2008 Section 6411(a) of the Affordable Care Act expanded RAC to Medicaid and required each State to begin implementation by January 1, 2012 Identification of overpayments and underpayments States & RAC vendor must coordinate recovery audit efforts RAC vendors reimbursed through contingency model 2
About HMS We provide cost containment services for healthcare payers We help ensure that claims are paid correctly (program integrity) and by the responsible party (coordination of benefits) As a result, our clients spend more of their healthcare dollars on the people entitled to them 3
HMS- Medicaid RAC Standards Reduce provider abrasion, provide education, customer service and limit administrative costs. Possess in depth knowledge of Michigan Medicaid policies, regulations and CHAMPS process. Maintain an understanding of the state s operating environment political, provider associations, agency goals. Experienced in coordinating with other state audit entities. Have established processes for a) Receiving and Formatting Medicaid Data, b) proven provider relations and c) seamless recovery function. 4
Overview of Review Process Analysis And Targeting Program Analysis Data Mining/Scenario Design State Approval Record Request Provider Contact Record Request/Receipt Tracking/follow up Review/Audit Notification and Recovery RN/Coder Review Physician Referral QA and Client Review/Approval Notification Letter Reconsideration/Appeal Recovery Support Education, Process Improvement Provider Association Meetings Program Recommendations Newsletter/Website 5
Analysis and Targeting Analysis And Targeting Program Analysis Data Mining/Scenario Design State Approval Diverse focus on multiple provider and claim types 360 degree claim review Clinical Regulatory Billing Target areas are presented to DCH with relevant regulatory references MDCH input and approval obtained HMS will review claims for both under and overpayments 6
Record Request Record Request Provider Contact Record Request/Receipt Tracking/follow up Initial record requests will be mailed to the address listed in CHAMPS as the correspondence address. Providers have 30 days from the date of the letter to submit records for review. Records can be submitted on paper or electronically on CD/DVD or hard drive. Please submit a copy of the HMS letter with all communication If sending a CD/DVD or hard drive, be sure to encrypt 7
Review / Audit Review/Audit RN/Coder Review Physician Referral QA and Review/Approval Types of Reviews Automated is applied in scenarios where improper payments can be identified clearly and unambiguously. Complex is required when analysis identifies a potential improper payment that cannot be automatically validated. Comprehensive panel of experts MI licensed physicians, Registered Nurses, Coders Data Analysts Financial Auditors HMS has 60 days to review records received and issue notification of determination 8
Notification and Recovery Notification and Recovery Notification Letter Reconsideration/Appeal Recovery Support Notification Letters Preliminary Findings Issued when claims are determined to be improperly paid (automated and complex) Final Notice of Recovery Issued when there is no response to Preliminary Findings letter (automated and complex) Technical Denial Issued when there is no response to record request (complex only) No Findings Issued when claims are determined to be properly paid (complex only) Reconsideration Requests Providers have the right to submit additional documentation after receiving a findings notification Appeals HMS will follow the current MI Appeals process as documented in the Administrative Code (R400.3402-R400.3424) Recovery Process Claim should be corrected in CHAMPS 9
Process Improvement Education, Process Improvement Provider Association Meetings Program Recommendations All Provider Listserv/Website Outreach presentations Work one-on-one with provider to identify process improvements and educate staff to reduce future billing errors Provide feedback to MDCH to assist with system updates to avoid future improper payments MDCH All Provider listserv used for updates on Statewide program HMS MI RAC Provider website provides transparency of process and upcoming audits CMS reporting for information on outcomes. 10
Timelines, Scope, & Medical Records Requests Look back period: Up to 3 years from date of service Scope: All provider types Exclusions: Any claims that are part of a previous/ongoing audit and claims that meet the 2 Midnight Rule for time frames 10/1/13 03/31/15 Record Request Limits: Records requested will not exceed 150 records per request or 500 in a 3-month period for any billing NPI 11
Currently Approved Issues Approval Date Scenario Name Description Regulations/Rules If in agreement with findings: 02/25/2013 Inpatient Overlapping (Automated) Inpatient hospital claims will be reviewed to determine if improper payments have been made due to providers submitting interim or duplicate billings with overlapping dates of service. Providers are not entitled to duplicate payments for the same service under any state or federal plan. Provider should VOID duplicate claim. 02/25/2013 Crossover Duplicates (Automated) Provider Medicaid claims will be reviewed to determine if duplicate payments were made for Medicare crossover claims. Providers are not entitled to duplicate payments for the same service under any state or federal plan. Provider should VOID duplicate claim. 04/18/2013 Inpatient Hospital Reviews Appropriateness of Setting (Complex) Inpatient Hospital claims with LOS 3 days or less will be reviewed to determine if an Outpatient or Observation setting was more appropriate. The Michigan Medicaid Provider Manual, Section 9 - Inpatient Hospital Authorization Requirements states All inpatient admissions must be medically necessary and appropriate and all services must relate to a specific diagnosed condition. Elective admissions, readmissions, and transfers for surgical and medical inpatient hospital services must be authorized through the Admissions and Certification Review Contractor (ACRC). The physician/dentist should refer to the Prior Authorization Certification Evaluation Review (PACER) subsection of this chapter for specific requirements. Medicaid does not cover services related to inappropriate or unnecessary inpatient admissions. Provider should VOID claim. 12
Currently Approved Issues Approval Date Scenario Name Description Regulations/Rules If in agreement with findings: 05/17/2013 DME Capped and Duplicate Rentals (Automated) DME claims will be reviewed to determine if improper payments have been made for rentals in excess of the capped rental period. Claims will also be reviewed to determine if duplicate payments were made for DME rentals. Medicaid Manual, Medical Supplier Section 1.8.B Items may be rented for a maximum period of 10 months. Providers are not entitled to duplicate payments for the same service under any state or federal plan. Provider should VOID claim or ADJUST claim lines by deleting those that have gone beyond the rental cap, and/or those that are duplicates. 06/10/2013 Improper Units (Automated) Physician, Outpatient, or DME claims will be reviewed to determine if claim line unit counts exceed the limit allowed. National Correct Coding Initiative MUE Guidelines and MDCH service limit published in appropriate fee screens dictate the appropriate units allowed. Provider should adjust the claim correcting the units to the appropriate claim line. 09/12/2013 DRG Validation (Complex) Inpatient claims will be reviewed to determine if the appropriate DRG code was assigned for payment purposes. These reviews will be done as a part of Appropriate Setting reviews currently under way when deemed appropriate. Inpatient DRG coding relates to the accuracy and completeness of the ICD-9- CM diagnosis and procedure codes used to assign the DRGs and determine payment. Medicaid Manual, General Information for Providers, Section 12.8, Claim Certification Providers certify by signature that a claim is true, accurate, and contains no false or erroneous information. Providers should adjust the claim to provide the appropriate ICD-9- CM codes as identified in the documentation. 13
Provider Resources 14
Provider Portal Overview The HMS Provider Portal is a secure website that allows providers to manage their RAC reviews More than 15,000 providers currently use HMS s Provider Portal Contact information can be updated by providers Contains HMS contacts 15
Provider Portal Secure website for each provider to manage reviews 16
www.medicaid-rac.com/miproviders/ Upcoming and Previous Event Details Approved Issues Resource Links Informational Documents Scope of Work Sample Notification letter FAQ Document Audit Process Document Copy of Presentation Slides Contact Information 17
Contact Information www.medicaidrac.com/miproviders/ 1-855-474-5113 mirac@hms.com Brenda McLean, MSA, CPC HMS Program Director Michigan Medicaid RAC Providers may also refer to the MDCH Provider Manual Directory Appendix for additional RAC contact information. To report Medicaid Fraud and Abuse, call toll free the DCH Office of Inspector General at 1-855-MI-FRAUD (643-7283); send a letter to PO Box 30479 Lansing, MI 48909; or submit an Online Complaint Form at www. Michigan.gov/fraud. 18
MDCH - Office of Inspector General Fraud Hotline 19