Illinois Medicaid Recovery Audit Contract RAC Overview February - PowerPoint PPT Presentation

Illinois Medicaid Recovery Audit Contract RAC Overview February 2017

 Provide information • Introduction to HMS • Illinois Medicaid RAC Program  Share Details on HMS Review Process Webinar Goals • Scenario Methodology • Approach and Overview • Review Process  Answer Common Questions 2

HMS Presenter Lara Wright Megless, HMS Regional Director 3

Background and Overview 4

 Vision: Making the healthcare system work better for everyone HMS Vision  Mission: We work passionately to increase the value of the and Mission healthcare system so that healthcare dollars can benefit more people. 5

 Medicare Modernization Act of 2003 created a demonstration project to identify Medicare Background on overpayments • Operational from 2005 through 2007 the Recovery • Made permanent in 2008 Audit  Section 6411(a) of the Affordable Care Act expanded RAC to Medicaid. Contractor • Identification of improper payments • Coordination of audit efforts with state audit efforts • Education to providers 6

Identify improper payments through analysis of paid Medicaid Claims. Deliver results grounded in quality, integrity and accuracy to policy. HMS Partner with the Single State Agency to Medicaid RAC ensure a fair and consistent process. Approach Ensure clear, concise, and timely communication with providers. Afford all providers their rights to appeal. 7

HFS Policy Review Scenario Analysis, Claims Data Mining System (Based on PData olicy Remediation, and Guidelines) Provider Education HMS Medicaid RAC Scenario Provider Improper Payment Life Cycle Reconsideration/ Scenario Appeals and Offset Approval from HFS Potential Improper Edits and Analytics, Payments Identified and Clinical Claim and Letters Mailed Review 8

Scope, Process, and Scenarios 9

Claim Edits and Analytics are applied in scenarios where improper payments can be identified clearly and unambiguously. Types of Reviews  Preliminary Findings  Reconsideration (If Applicable)  Final Notice of Recovery 10

Clinical Claim Review is required when analysis identifies a potential improper payment that cannot be automatically validated Types of Reviews  Record Request  Preliminary Findings  Reconsideration (If Applicable)  Final Notice of Recovery 11

 Look back period : Up to three years from the date of service  Scope: Includes all provider types  Initial records request for Clinical Claim Review: Submit records to HMS no later than 30 calendar days from the date the records request letter is received.  When a Clinical Claim Review audit Preliminary Findings letter Review Process is issued: Submit reconsideration records and documentation to HMS no later than 30 days from the date the Preliminary Findings Scope and letter is received, if applicable.  When a Claim Edits and Analytics audit Preliminary Findings Timing letter is issued: Submit Reconsideration documentation, if applicable, to HMS no later than 30 days from the date the Preliminary Findings letter is received.  Current HFS appeals process will be utilized  Recoupment: The recoupment process only begins after the audit has been finalized and the provider has had an opportunity to submit reconsideration documentation or appeal. Do not make payment adjustments. Recoupment will occur either by payment withhold or cashier’s or certified check. 12

Edits and Analytics Clinical Claim Review Agree – No further action is necessary 30 Days to submit medical records at this time. Do not make payment (fax or mail paper, or mail CD/DVD) adjustments. Disagree – 30 Days to submit 60 Days for HMS to review and notify Reconsideration documentation via Preliminary Findings Letter in response to Preliminary Review Findings Letter Disagree – 30 Days to Continued disagreement after receipt Timing of Final Notice of Recovery letter – 60 Reconsideration documentation days to submit appeal request to in response to Preliminary State of IL Findings Letter Agree – submit Payment Agreement to HMS, claims will be submitted to HFS for offset on future remittance or repayment by Cashier’s or Certified check. Do not make payment adjustments. Continued disagreement after receipt of Notice of Recovery letter – 60 days to submit appeal request to State of IL 13

 Ambulance During Inpatient  DME while Inpatient  DME During LTC Approved Edits  Incorrect Discharge Status Code and Analytics  Not a New Patient Scenarios  Preadmission Testing  Office Visit During Inpatient  Modifier 57 14

 Inpatient Hospital Review: Appropriateness of Approved Setting Clinical Claim  Newborn DRG Upcoding Review  Inpatient DRG Validation Scenarios  Hospice Services 15

Approved  Credit Balance Financial Audit  Long Term Care Scenarios 16

Resources 17

 Outreach and Education Provider • Attend provider association meetings Education and • Communication through webinars and HMS RAC website  Transparency Transparency • Schedule of events and upcoming audits listed on http://hms.com/us/il-providers/home/ 18

 IL Provider-specific Website: Provider http://hms.com/us/il-providers/home/ Contacts  IL Provider-specific Toll-free Number: 1(855) 699-6292 19

HMS IL RAC Specific Contact Information 20