claims compliance analysis amy kanter, sbs auditor michigan department of health and human services...
TRANSCRIPT
Claims Compliance Analysis
Amy Kanter, SBS AuditorMichigan Department of Health and Human Services
2015 SBS Conference – Traverse City, MI
August 17 & 18, 2015
1
Background(MI Medicaid Provider Manual)
The Centers for Medicare & Medicaid Services (CMS) require Michigan SBS providers to submit procedure specific fee for service claims for all Medicaid allowable services
These claims do not generate a payment but are required by CMS in order to monitor the services provided, the eligibility of the recipient, and provide an audit trail
If the claim volume decreases significantly or drops to zero in any two consecutive months, all interim payments will be held until the provider is contacted and the issue resolved
MDHHS will monitor provider claim volume to make sure that this mandate is followed
Background cont.(MI Medicaid Provider Manual)
It is the intent of the State of pursue, when necessary, remedial action or implement a Corrective Plan if the ISDs or their vendors are not in compliance with Medicaid policy and procedures. If these actions are not successful, a payment freeze will be implemented and sanctions put in place until the matter is resolved. ISDs are responsible for the actions of their vendors
Historical Trends
Aug-1
3
Sep-1
3
Oct-1
3
Nov-1
3
Dec-1
3
Jan-
14
Feb-1
4
Mar
-14
Apr-1
4
May
-14
Jun-
14
Jul-1
4
Aug-1
4
Sep-1
4
Oct-1
4
Nov-1
4
Dec-1
4
Jan-
15
Feb-1
5
Mar
-15
Apr-1
5
May
-15
Jun-
150
5
10
15
20
25
30
Number of ISD's Below 85%
Number of ISD's Below 85%
Monthly Claims Comparison Process Queries are run to pull the claims Information is compiled into a spreadsheet and a
rolling average is calculated Can track long term trends rather than short term
billing variances Percentages are identified Letters/Information Sheets are issued Response letters are issued for the documentation
provided
Claims Pull Process
Claims are pulled with the following criteriaBy NPI numberPulled by date of serviceClaim type G- School Based ServicesLimited to a paid date of the 18th of each
month
Psych, Speech, & Transportation
Psych has been removed due to prior controversy Speech has been removed due to recent changes in
the licensure Transportation is redundant as there are supposed
to be medical services on the same day and would be counted in the Medical portion
Our goal is to compare the numbers as equally across the ISD’s as possible
Claim Process Steps
Information is input into a spreadsheet Calculate rolling averages Calculate a lag time in claims submissions
to determine an average for a look back period to allow time for claims to be paid after submitted
Calculate percentages
Letters Issued
Letter 1- Warning Letter Letter 2- 30 Day Letter Letter 3- Suspension Letter
In response to all required documentation- a response letter is issued to the ISD
Information sheets are also provided to reflect the trends of the claims
Information Sheet Provided
First page shows the actual claims that were paid by month Graph reflects the rolling averages and trends that may help identify
problems Second portion shows the 12 month rolling average calculated Last section reflects the percentages calculated by dividing the
current 12 month rolling average by the prior 12 month rolling average period
Required Documentation
Communication is important!! Documentation requires detail the reason for the
drop in claims Documentation required the details on the corrective
measures that will be put in place Documentation requires a date of which the
corrective measure will start taking place and claim volumes should start to rise
Effects of Non-Compliance
Interim payments can be suspended until the 85% level is reached
If an ISD comes into compliance at any time during this process, the process stops and missed monthly payments can be made up if requested in writing
Risks of non-compliance on the part of MDHHS CMS sanctions Possible loss of the program
Reasons Behind Drop In Claims
Parental consent changes CHAMPS edit issues Reduction in staff and students Changes in federally funded employees Changes in who does the billing Other issues specifically within the ISD
** Reasons require specific detailed information
Claim Resolution Steps
Determine if the problem lies within the claim being paid. We can provide assistance to help determine the cause of the denials
Identify where the issues lie and possibly using the information sheet to provide trending information over the years
Conference calls
Proactive Steps – ISD
Staff training and follow up Regular evaluation of the RA to stay on top of
denials and their reason Review the internal processes Know program changes Know procedure code changes Identify claim denials and causes