Getting Acquainted with Audits and Reviews

1. Getting Acquainted with Audits and Reviews

2. Don’t feel like the roof fell in. - Be prepared -

3. Introductions • PERM: Payment Error Rate Measurement • RAC: Recovery Audit Contractors • Myers and Stauffer • Credit Balance Audit • Medicaid Integrity Program Audits • Disproportionate Share Audit New New

4. PERM: Payment Error Rate Measurement • Requested by: CMS (Center for Medicare & Medicaid Services) • Scope: Nation-wide (Federal) • What is measured: State’s rate of Medicaid billing errors • What is reviewed: State’s processes; provider documentation • Subcontracted by: Livanta (medical reviews); HDI: Health Data Insights (data processing) • Providers affected: All Alaska providers that bill Medicaid

5. RAC: Recovery Audit Contractors • Requested by: CMS (Center for Medicare & Medicaid Services) • Scope: Nation-wide (Federal) • What is measured: Improper Medicare payments • What is reviewed: Compliance with Medicare coding rules or medical necessity • Subcontracted by: (HDI) Health Data Insights • Providers affected: Medicare enrolled providers

6. RAC Training August 17 & 18, 2009 MONDAY, AUGUST 17 @ 9:30 a.m. – LIVE PRESENTATION An in-person CMS / HDI Recovery Audit Contractor (RAC) Review Presentation for Alaska hospital and nursing home staff The presentation will be held in the Willow Room at Providence Anchorage Medical Center (PAMC).  The Willow Room is downstairs across from the hospital’s cafeteria; Building C of the Medical Center complex on Providence Drive. The session is expected to last approximately two hours, but if there are a lot of questions, it could go longer, ending closer to noon. 

7. RAC Training TUESDAY, AUGUST 18 @ 9:30 a.m. – TELECONFERENCE/VIDEO PRESENTATION This presentation will be a repeat of Monday’s presentation and will be both teleconferenced and video-conferenced. Teleconference (Voice Only): The conference call number is: 1-888-346-3950 Entry code for the call line is 624191 (followed by the # sign). Video-conference:         Please notify Katy Branch, the ARTN’s Education Coordinator, by email (katy@ashnha.com)by Monday, noon, August 17th, of your desire to be connected via video.  The session is expected to last approximately two hours, but if there are a lot of questions, it could go longer, ending closer to noon. 

8. Myers and Stauffer • Requested by: Alaska State Legislature, via AS 47.05.200 • Scope: State-wide • What is measured: Overpayment identification • What is reviewed: Provider claims • Subcontracted by: Myers and Stauffer • Providers affected: All Alaska providers that bill Medicaid

9. Credit Balance Audit • Requested by: Department of Health & Social Services, Division of Health Care Services • Scope: State-wide • What is measured: Credit balances • What is reviewed: Provider claims • Subcontracted by: HMS (Health Management Services) • Providers affected: All Alaska Medicaid providers

10. Medicaid Integrity Program (MIP) Audits • Requested by: CMS (Center for Medicare & Medicaid Services) • Scope: Nation-wide (Federal) • What is measured: Overpayment Identification • What is reviewed: Provider Claims • Subcontracted by: HMS (Health Management Services) • Providers affected: All Alaska Medicaid providers

11. More on the MIP • What are the Audit MICs? Audit Medicaid Integrity Contractors (Audit MICs) are entities with which CMS has contracted to perform audits of Medicaid providers. HMS is the contractor for Alaska. The overall goal of the provider audits is to identify overpayments and to ultimately decrease the payment of inappropriate Medicaid claims.

12. More on the MIP • Which providers will be subject to audit? Medicaid providers, including, but not limited to, fee-for service providers, institutional and non-institutional, as well as managed care entities. • How are providers selected? Data analysis by other CMS contractors and referrals by State agencies. CMS will ensure that audits will not duplicate State audits of the same providers nor interfere with potential law enforcement investigations.

13. When a provider receives a Notification Letter that it has been selected for audit: • Gather requested documents as instructed, within the requested timeframes. CMS contractors have the authority to request and review copies of provider records, interview providers and office personnel, and have access to provider facilities. • Generally, providers will have at least two weeks before the start of an audit to make their initial production of documents to the Audit MICs. Audit MICs will be mindful of state-imposed requirements concerning record production and may accommodate reasonable requests for extensions provided neither the integrity nor the timeliness of the audit is compromised. • The Audit MICs will also contact the provider to schedule an entrance conference. Notification Letters will identify a primary point of contact at the Audit MIC if there are specific questions about the Notification Letter or the audit process.

14. Following the completion of the audit: • The Audit MIC prepares a draft audit report • The State and the Provider review and comment on the findings • CMS prepares a revised draft report • The State reviews the revised draft with the option to make additional comments • CMS finalizes the audit report, specifies any identified overpayment, and sends the final report to the State and the Provider The State will pursue the collection of any overpayment in accordance with State law. Providers have full appeal rights under State law. The Audit MICs will be available to provide support and assistance to the States throughout the State adjudication of the audit.

15. DSH: Disproportionate Share Audit • Requested by: CMS (Center for Medicare & Medicaid Services) • Scope: Nation-wide (Federal) • What is measured: Appropriateness of DSH payments • What is reviewed: State’s processes; provider documentation • Subcontracted by: Myers and Stauffer • Providers affected: Hospitals receiving state DSH payments

16. Auditors are not psychics I sense a complete review of systems…but the crystal ball is cloudy regarding a chief complaint and the exam… • Medical Record Reviewers do not fill in gaps in a note • Documentation is critical to supporting services provided • Each visit must stand alone • Reviewers will not look back at prior notes to support a level of service Note Note

17. Quiz Time! HMS is the contractor for which audit(s)? A. Recovery Audit Contractors (RAC) B. Medicaid Integrity Program (MIP) Audit C. Credit Balance Audit D. Both B and C

18. When a provider receives a Notification Letter that it has been selected for a MIP audit, they should: A. Call Medicaid or Medicare to find out why B. Gather requested documents as instructed C. Consult a lawyer for legal advice D. Schedule an entrance conference with the audit MIC.

19. Which audit has been requested by the Alaska State Legislature , via AS 47.05.200? A. Myers and Stauffer • B. PERM: Payment Error Rate Measurement • C. Disproportionate Share Audit D. None of the Above

20. Thank You Questions and Discussion