Minnesota Department of Human Services Recovery Audit Contract (RAC) Provider Outreach & Education...
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Minnesota Department of Human ServicesRecovery Audit Contract (RAC)
Provider Outreach & Education Presentation April 18, 2013
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Agenda • Introduction• HMS Overview• Minnesota’s Medicaid RAC Program• Complex and Credit Balance Reviews:
MethodologyApproach & OverviewReview Process
• Provider Portal• Answer Common Questions
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Health Management Systems
Presenters Lonnette Chilefone, Director, Minnesota Programs Joleen Bond-Livingston, Vice President, Recovery Audit
Glenda Lloyd, Manager, DRG Coding Validation - RAC
Mary Leigh Covington, Divisional Vice President Credit Balance
Jeffrey Norman, Sr. Program Integrity Provider Services Supervisor
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HMS OVERVIEW
JOLEEN BOND-LIVINGSTONVICE PRESIDENT, RECOVERY AUDIT
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About HMS• We provide cost containment services for healthcare
payers
• We help ensure that claims are paid correctly (program integrity) and by the appropriate responsible party (coordination of benefits)
• As a result, our clients spend more of their healthcare dollars on the patients themselves
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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
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HMS- Medicaid RAC StandardsReduce provider abrasion, provide education, customer service and limit administrative costs.
Possess in depth knowledge of Minnesota Medicaid policies, regulations and MMIS processes.
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.
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RAC Process: Flow
Minnesota Policy Review
Pilot Data Mining (Based on Policy
Guidelines)
Recovery
Improper Payment Scenarios
Design Approval from Minnesota
Automated &
Complex Review
Trend Analysis &
Provider Education
System Remediation
Transparency &Collaboration
with Minnesota
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Key RAC Considerations• Diverse focus on multiple provider and claim types
• Minnesota approval on all initiatives
• Supplement and wrap around existing Minnesota efforts
• Pilot approach to confirm issue/scenario
• Comprehensive provider education
• Same appeal rights as other DHS post-payment reviews
• 360 degree claim review– Clinical– Regulatory– Billing
• Comprehensive panel of experts– Physicians, Nurses, Coders– Data analysts– Financial auditors
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Overview of Review Process
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Analysis And Identification
Education, Process Improvement
Review/Audit
• Program Analysis • Data Mining/Scenario Design• State Approval
Record Request• Provider Contact• Record Request/Receipt• Tracking/follow up
• RN/Coder Review • Physician Referral• QA and Client Review/Approval
Notification and Recovery
• Notification Letter• Reconsideration/Appeal• Recovery Support
• Provider Association Meetings• Program Recommendations• Newsletter/Website
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HMS RAC Support Staff• Experienced staff performing reviews according to
provider types included in contract:– Certified Coders– Registered nurses– Specialized Therapy Professionals – Review panel of over 1,000 physicians
• HMS has in-depth knowledge of– Minnesota Medicaid billing & reimbursement
practices– Claims adjudication process– Medicaid data processed by Minnesota MMIS
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HMS Audit Support
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HMS Provider Services’ staff are practiced at establishing and maintaining effective
communication with providers and strive to resolve provider issues on the first call
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MINNESOTA MEDICAID RAC
LONNETTE CHILEFONEDIRECTOR, MINNESOTA PROGRAMS
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Minnesota Audit Areas• Complex Reviews – Clinical based on DRG
– Three year look back from paid date
• Credit Balance Reviews – Financial
– Five year look back from paid date
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Complex Reviews• When analysis identifies a potential improper payment that cannot be automatically validated
• Claims flagged for further review
• Additional documentation is requested
• Audit to determine if improper payment
•Findings communicated with provider
•Look back period is three years from paid date15
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Credit Balance Reviews
•Not clinical reviews
•Financial reviews
•Payments and adjustments exceed the claim cost
•Can occur as a result of many variables
•Provides for identification of Root Cause
•Look back period is five years from bill date
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Minnesota Medicaid RAC Program Audit Areas
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Financial Audits Clinical Complex Reviews
Current Clinical Complex
Review DRG Validation Audit
Credit Balance
Provider Types Approved to Date
Acute Care Hospitals Acute Care Hospitals Acute Care Hospitals
Medical Record Limits
Not applicable- Financial Audit only
150 records per month not to exceed 450 per quarter
* Note: DHS may authorize exception on a case-by-case basis.
Provider Type :In-patient Hospital
• 150 records per month• Audit Frequency TBD
Type of Audit On-site or desk reviews Desk reviews Desk reviews; few could become on-site
Audit Notification HMS letterheadAccompanied by the DHS authorizationletter on DHS letterhead
HMS letterheadAccompanied by the DHS authorizationletter on DHS letterheadletterhead
HMS letterheadAccompanied by the DHS authorizationletter on DHS letterhead
Types of Records • In patient and outpatient hospitalization
• Medical records• Varies by audit
• Medical records For example:Discharge summaryPhysician ordersLabs, x-raysMedication Records
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Audit Areas Continued
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Credit Balance Audit
Complex Reviews
CurrentComplex Review DRG Validation
Audit
Who to Contact? HMS Provider services
Source of Audits and Frequency
All acute care hospitals: variable based on audit results
Data mining and algorithms: variable based on audit results
Data mining and algorithms: variable based on audit results
Claim Selection Claim-by-claim Varies per audit. May use sampling in the future.
Claim-by-claim
Entrance Conference
Yes on-site or by conference call
No, but provider may contact HMS Provider Services anytime
No, but provider may contact HMS Provider Services anytime
Exit Conference Yes on-site or by conference call to review worksheets
No, but provider may contact HMS Provider Services anytime
No, but provider may contact HMS Provider Services anytime
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Review Process
• Providers will receive audit notifications HMS letterhead that will be accompanied by the DHS authorization letter on DHS letterhead.
• Audits will be conducted as desk reviews by experienced certified coders with access to a panel of physicians.
• During this period, HMS may be in contact with the provider to ask questions or to request additional information. The provider may contact HMS at any time to discuss their review.
• After the review process is completed, result letters are sent to providers to communicate:
ˍ Detailed description of final determinations ˍ Improper payment amount ˍ Option to appeal
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Review Process• Receipt of records is extremely important to accurately and effectively
conduct the audits in a timely manner.
• Initial records request requires receipt of the records by HMS, no later than the end of the 30th business day from receipt of the letter documented by standard postal delivery tracking methods
• Failure to produce records will result in the determination that your agency was improperly paid for all services under review for the requested dates of service resulting in a refund request for these amounts
• Case reviews to be completed within 60 days from receipt of complete medical records
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Review Process• Extrapolation will NOT be applied for hospital DRG inpatient review
overpayment amounts identified
• Current Minnesota appeal process will be utilized• Concentrated effort made to assure that audit letters are detailed and
specific, helping reduce the burden of appeal on all parties
• Providers are encouraged to call HMS’ Provider Services to discuss and
resolve issues
MN RAC toll free number: 855-394-8063• Call volumes are monitored to address potential issues which may be used in
educational sessions
Questions for DHS may be sent via email to [email protected]
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Review Process Responsibilities
HMS• Send Draft Audit Findings Letter with
results of review.
• Work one-on-one with the provider to resolve any disputed cases, if provider requested reconsideration.
• Send Final Calculation of Overpayment letter to provider indicating remaining interest owed after claim adjustment requests have been processed.
• Support appeals process when applicable
Providers• Review Draft Audit Findings and respond
within 30 calendar days of signed receipt of letter
• If in agreement with findings remit payment within 30 days
• If not in agreement with findings, submit a request for reconsideration within 30 days
• Review Final Calculation of Overpayment letter and:
● Agree and proceed with repayment, or
● File an appeal within 30 days
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DIAGNOSIS RELATED GROUP (DRG) AUDITS
Glenda Lloyd, MBA, BS, RHIA
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Diagnosis Related-Group(DRG) Validation
• The purpose of DRG validation is to ensure that diagnostic and procedural information and the discharge status of the member, as coded and reported by the hospital on its claim, matches both the attending physician's description and the information contained in the member’s medical record.
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Validation Sets
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• Target analysis identifies situations in which demographics, billing attributes, diagnosis codes, procedure codes, and/or factors affecting the DRG assignment appear to be inconsistent with other attributes of the claim or case documentation within the medical record, and in instances where providers have billed for a higher paying DRG in an outlier status.
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CREDIT BALANCE OVERVIEW
MARY LEIGH COVINGTONGDIVISIONAL VICE PRESIDENT, CREDIT BALANCE
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• 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
• 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
HMS Credit Balance Audit (CBA) Overview
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• 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?
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Approach
•COB•Retroactive payments•Double payments• Incorrect payments
ROOT CAUSES
35% 65%MONETARY
NON-MONETARY
HMS provides a root cause analysis to prevent future credit balances.
• Inaccurate postings•Charges written off in
excess of amounts actually billed
•Provider A/R collection systems modeling net revenue at the time of
billing Not all overpayments are credit
balances; not all credit balances are overpayments
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1. Audit notice and Initial Contact 2. Entrance Conference3. Review all active and inactive accounts in credit
balance status as of the notice date– Remote/Desk Reviews– Provider Self Disclosure
4. Review and Finalize findings– Provider Attestation Process
5. Exit Conference6. Recovery and Reporting
Credit Balance Audits: Process Overview
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• 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 MN DHS
Credit Balance: Provider Education
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Minnesota Provider PortalJeff Norman
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Provider Portal• The Provider Portal is a secure
website that allows providers 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.
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Provider Portal
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Secure website for each provider to manage reviews
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Provider Portal
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Provider Portal
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Provider Portal
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Provider Portal
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Provider Portal
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Provider Portal
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Questions