GEORGIA MEDICAID PROGRAM INTEGRITY AND RAC: WHAT YOU CAN EXPECT IN 2014

PRESENTATION TO THE HOMETOWN HEALTH

14TH ANNUAL FALL CONFERENCE CALLOWAY GARDENS GA, NOVEMBER 14, 2013

MEDICAID RAC: OVERVIEW

• Perform audits to identify mispayments• Includes both FFS and CMO claims• Five-year “look back”• Medical director and certified coders required• Provider education and outreach• Coordination with other audit contractors and

programs• Limitation on medical record requests• Administrative review process

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MYERS AND STAUFFER LC

• CPA firm with 18 offices nationwide• Healthcare consulting, auditing and

reimbursement services• Strictly government clients (45 States and Fed

government)• Selected as Georgia Medicaid RAC effective April 2,

2012

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MSLC GEORGIA RAC TEAM

• Project Director – Michael Johnson, CPA and CFE

• Project Manager – Scott Smeal, JD• Medical Director – Joel Goldstein, MD• Analysts, Nurses, Coders, Data Analysts• Additional Staff as Needed

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RAC AUDITS

• Developed in consultation with and subject to the approval of the DCH IG

• Three basic types: “Automated” or claims-based, without

medical records “Complex” with records review (desk or onsite) Self-audits

• Unbiased review to determine mispayments (both overpayments and underpayments)

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AUDIT PROCEDURES

• Complex audits typically begin with request for records

• Initial Findings Letter• Provider can agree or request administrative

review• Final Decision• Administrative Appeal in accordance with Chapter

500, Part I, Policies and Procedures for Medicaid/Peachcare for Kids™

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FRAUD REFERRALS

• MSLC required by contract and Federal law to refer instances of suspected fraud

• Referrals are made to DCH Deputy Inspector General

• DCH decides to refer to MFCU and/or other appropriate Federal and/or State law enforcement or regulatory agencies

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PROVIDER EDUCATION AND OUTREACH

• Toll-Free Number (855) 201-4570• MSLC RAC website:

http://georgiamedicaidrac.mslc.com• Frequently asked Q & A• Points of Contact• Audit Policies and Protocols• Audit Agenda• News and Updates

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RAC PROVIDER RELATIONS (RPR) ADVISORY COMMITTEE

• Established to promote provider input about general RAC issues

• 15 members, including 4 from DCH, 4 from MSLC and 7 from the provider community

• Quarterly meetings• One-year term• No compensation

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ACTIVE AUDITS

• Hospital transfer pricing• Patient liability• Fair rental value (FRV)• Neonatal Intensive Care Unit (NICU) services• Hospital outpatient related to inpatient• Physician services: allergy, drug screen,

global services

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PRELIMINARY AUDITS

• DME• DRG validation• Home health services• Hospice• Duplicate payments• NCCI/MUE

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MYERS AND STAUFFER LC

Located in Georgia-Pacific Center at133 Peachtree Street, NE – Suite 3150

Atlanta, GA 30303

(404) 524-0775(404) 524-0782 (FAX)

Toll-Free (855) 201-4570Michael D. Johnson or Scott A. Smeal

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QUESTIONS?

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