Minnesota Department of Human ServicesRecovery Audit Contract (RAC)Provider Outreach & Education Presentation April 18, 2013
Agenda IntroductionHMS OverviewMinnesotas Medicaid RAC ProgramComplex and Credit Balance Reviews:MethodologyApproach & OverviewReview ProcessProvider PortalAnswer Common Questions
2 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
JOLEEN Bond-livingstonVice President, Recovery Audit
About HMSWe provide cost containment services for healthcare payersWe 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 themselves5
5Background Recovery Audit ContractorMedicare Modernization Act of 2003 created a demonstration project to identify Medicare overpaymentsThe program was operational from 2005 through 2007Following 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, 2012Identification of overpayments and underpaymentsStates & RAC vendor must coordinate recovery audit effortsRAC vendors reimbursed through contingency model 66HMS- Medicaid RAC Standards77RAC Process: Flow8Transparency &Collaboration with Minnesota
Key RAC ConsiderationsDiverse focus on multiple provider and claim typesMinnesota approval on all initiativesSupplement and wrap around existing Minnesota effortsPilot approach to confirm issue/scenarioComprehensive provider educationSame appeal rights as other DHS post-payment reviews360 degree claim reviewClinicalRegulatoryBillingComprehensive panel of expertsPhysicians, Nurses, CodersData analystsFinancial auditors
99Overview of Review Process10Analysis And IdentificationEducation, Process Improvement Review/Audit Program Analysis Data Mining/Scenario Design State ApprovalRecord 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 10
HMS RAC Support StaffExperienced staff performing reviews according to provider types included in contract:Certified CodersRegistered nursesSpecialized Therapy Professionals Review panel of over 1,000 physiciansHMS has in-depth knowledge ofMinnesota Medicaid billing & reimbursement practicesClaims adjudication processMedicaid data processed by Minnesota MMIS
11HMS Audit Support12HMS Provider Services staff are practiced at establishing and maintaining effective communication with providers and strive to resolve provider issues on the first call
12Minnesota Medicaid RAC
Lonnette chilefonedirector, minnesota programs
Minnesota Audit AreasComplex Reviews Clinical based on DRG Three year look back from paid date
Credit Balance Reviews Financial Five year look back from paid date14
14Complex 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 date
15Credit Balance ReviewsNot clinical reviewsFinancial reviews Payments and adjustments exceed the claim costCan occur as a result of many variables Provides for identification of Root Cause Look back period is five years from bill date
16 Minnesota Medicaid RAC Program Audit Areas17Financial AuditsClinical Complex ReviewsCurrent Clinical Complex Review DRG Validation Audit Credit Balance
Provider Types Approved to DateAcute Care HospitalsAcute Care HospitalsAcute Care HospitalsMedical Record LimitsNot applicable- Financial Audit only150 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 TBDType of AuditOn-site or desk reviewsDesk reviewsDesk reviews; few could become on-siteAudit Notification HMS letterheadAccompanied by the DHS authorizationletter on DHS letterheadHMS 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 17 Audit Areas Continued18Credit Balance Audit Complex ReviewsCurrentComplex Review DRG Validation Audit Who to Contact? HMS Provider servicesSource of Audits and FrequencyAll acute care hospitals: variable based on audit resultsData mining and algorithms: variable based on audit resultsData mining and algorithms: variable based on audit resultsClaim SelectionClaim-by-claimVaries per audit. May use sampling in the future.Claim-by-claim
Entrance ConferenceYes on-site or by conference callNo, but provider may contact HMS Provider Services anytimeNo, but provider may contact HMS Provider Services anytime
Exit Conference Yes on-site or by conference call to review worksheetsNo, but provider may contact HMS Provider Services anytime
No, but provider may contact HMS Provider Services anytime
18Review ProcessProviders 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:Detailed description of final determinations Improper payment amount Option to appeal
19Review ProcessReceipt 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 records20Review ProcessExtrapolation will NOT be applied for hospital DRG inpatient review overpayment amounts identifiedCurrent Minnesota appeal process will be utilizedConcentrated effort made to assure that audit letters are detailed and specific, helping reduce the burden of appeal on all partiesProviders are encouraged to call HMS Provider Services to discuss and resolve issues MN RAC toll free number: 855-394-8063Call volumes are monitored to address potential issues which may be used in educational sessionsQuestions for DHS may be sent via email to DHS.RAC@state.mn.us2121Our management wants some way for providers to ask questions of DHSReview Process ResponsibilitiesHMSSend 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 ProvidersReview 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, orFile an appeal within 30 days
22Diagnosis Related Group (DRG) audits
Glenda Lloyd, MBA, BS, RHIA
Diagnosis Related-Group(DRG) ValidationThe 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 members medical record.
Validation Sets25Target 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.25Credit Balance overview
Mary Leigh CovingtongDivisional Vice President, Credit Balance
27Currently serves 24 State Medicaid agencies, Medicaid Managed Care Organizations (MCO) and Commercial Insurance Plans