West Virginia Department of Health and Human Resources:

1. West Virginia Department of Health and Human Resources: An Inside Look at Medicaid Credit Balance Auditing HMS Inc. 5615 High Point Dr Irving, TX 75038

2. HMS is contracted with WV DHHR to conduct Medicaid credit balance reviews in order to determine if overpayments exist. HMS reviews all acute care facilities throughout the state of West Virginia. HMS also reviews facilities in surrounding states such as KY, OH, PA, etc. HMS has had a relationship with WV DHHR for over 20 years. Currently serves 24 State Medicaid agencies, Medicaid Managed Care Organizations (MCO) and Commercial Insurance Plans 14 years of experience working with providers on credit balance audit projects HMS Background

3. HMS Credit Balance Audit (CBA) Overview • Credit Balances Audits (CBAs) are focused on financial reimbursements to the provider • Primarily the CBAs are focused on reviewing the Provider’s Accounts Receivables (AR), Remittance Advices (RA), Explanation of Benefits (EOB) and miscellaneous relevant financial documents. • Experience determining and communicating with the provider the root cause of the identified overpayments or accounts resulting in credit balances

4. A credit balance occurs when the sum of payments received plus adjustments exceed the total charges on a claim Just because an account is sitting in a credit balance does not mean money is due back to the payer Common causes of credit balance include: Payments from third party payors and from Medicaid Duplicate Medicaid payments Charge reversals/adjustments/transfers Duplicate adjustments made to an account What is a Credit Balance?

5. Approach ROOT CAUSES NON-MONETARY • Inaccurate postings • Charges written off in excess of amounts actually billed • Provider A/R collection systems modeling net revenue at the time of billing MONETARY 65% 35% • COB • Retroactive payments • Duplicate payments • Incorrect payments Not all overpayments are credit balances; not all credit balances are overpayments HMS provides a root cause analysis to prevent future credit balances.

6. Three Types of Credit Balance Audits • Amnesty/Self Disclosure Review • On Site Review • Remote/Desk Review

7. Hospital Payment Report Quarterly Medicaid spend In state vs out of state Self Disclosure Letter 30 day deadline Refund Resource Worksheet Electronic voids/Live check refunds Final Report Electronic voids verified Live checks received Final report and live checks forwarded to the state Credit Balance Audit Process:Amnesty/Self Disclosure

8. Credit Balance Audit Process:On Site • On Site Notification Letter • Initial Contact • Official Request for (systems-generated) credit balance report • Pre Review Attachment • Two week deadline to submit documentation • Analyze credit balance report • Review scheduled • On Site Review • Entrance Conference • Review of patient accounts • Identify refunds • Exit Conference • Overpayments refunded within 14 days • Final report and live checks forwarded to the state

9. Credit Balance Audit Process:Remote/Desk • Notification Letter • Same process as on site • Determine that on site review is not warranted • Documents requested • < 60 accounts • Remote/Desk Review • Documents received in the Atlanta office • Review conducted within 1 week of receipt of documents • Findings communicated to provider contact • Overpayments refunded within 14 days • Final report and live checks forwarded to the state

10. Open communication with providers throughout the audit process Root cause analysis assists providers in preventing future overpayments Insure providers are up to date on the latest billing and reimbursement methods utilized by WV DHHR Partner with providers to establish an efficient process for conducting credit balance reviews Credit Balance: Provider Education

11. Credit Balance Audits: Key Contacts • Self Disclosure Reviews – Eve Garcia • eve.garcia@hms.com • T: 469.359.4416 • On Site Reviews – Paul Triay • paul.triay@hms.com • 646.427.5682 • Audits Supervisor – Lorenzo Jackson • lljackson@hms.com • 678.564.1166 x2109 • Program Director – Rick Levock • rlevock@hms.com

12. Questions