virginia recovery audit contractor provider outreach
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Virginia Recovery Audit Contractor Provider Outreach. April 23, 2013. Agenda. Introduction HMS Overview Medicaid RAC Review Process Provider Outreach & Education Provider Portal. About HMS. We provide cost containment services for healthcare payers. - PowerPoint PPT PresentationTRANSCRIPT
April 23, 2013
Virginia Recovery Audit ContractorProvider Outreach
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Agenda
► Introduction
► HMS Overview
► Medicaid RAC Review Process
► Provider Outreach & Education
► Provider Portal
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About HMS
We provide cost containment services for healthcare payers
We help ensure that claims are paid correctly (program integrity)
As a result, our clients spend more of their healthcare dollars on the people entitled to them
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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’ s Medicaid RAC Standards
Reduce provider abrasion, provide education, customer service and limit administrative costs.
Possess in depth knowledge of VA Medicaid policies, regulations and MMIS processes.
Maintain an understanding of the state’s operating environment – provider associations, agency goals.
Experienced in coordinating with other state audit entities.
Have established processes for receiving and formatting Medicaid data and proven provider relations
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Overview of Review Process
Analysis And Targeting
Record Request
Review/Audit
Notification and Recovery
Education, Process Improvement
• Program Analysis • Data Analytics/Scenario
Design• State Approval
• Provider Contact• Record Request/Receipt• Tracking/follow up
• RN/Coder Review • Physician Referral• QA and Client Review/Approval
• Notification Letter• Re-review/Appeal
• Provider Association Meetings• Program Recommendations• Newsletter/Website
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RAC Process Flow
Virginia Policy Review
Pilot Data Analytics (Based on Policy
Guidelines)
Recovery & Appeal
Improper Payment Scenarios
Design Approval from Virginia
Automated &
Complex Review
Trend Analysis &
Provider Education
System Remediation
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Virginia Medicaid RAC Staff
HMS has experienced staff performing reviews, including:• Certified Coders• Registered Nurse reviewers
• Review panel of licensed Physicians
HMS has in-depth knowledge of:• Virginia Medicaid specific billing and reimbursement practices• Claims adjudication process
• Virginia Medicaid data processed by the Virginia MMIS
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Virginia Medicaid RAC ReviewsAutomated Review is applied in scenarios where improper payments can be identified clearly and unambiguously.
1. A Preliminary Findings of Fact letter is generated notifying providers of:• Payment error• Related policy rule/criteria/regulation• Amount of the improper payment
2. Providers have the opportunity to respond to each determination and provide additional information.
3. As applicable, HMS reviews any additional information, and re-evaluates whether an improper payment exists based on Virginia’s Medicaid policy.
4. After the re-evaluation process, Final Overpayment letters are sent to providers. The letter communicates:
• Detailed description of final determinations • Improper payment amount • Recovery process• Option to appeal
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Virginia Medicaid RAC ProtocolAutomated Review Provider response to Preliminary Finding of Fact letter: 30 calendar
days
HMS issues Final Audit report
Provider response to Final Audit report: 30 calendar days to appeal from receipt of final audit report as required by Virginia Administrative Code.
If provider agrees or fails to respond to final audit report, HMS notifies Virginia DMAS and recoupment efforts will begin.
If the provider appeals no recoupment efforts will take place until the appeal process or pre-hearing conference process is completed and a final decision has been rendered.
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Virginia Medicaid RAC ReviewsComplex Review is required when analysis identifies a potential improper payment that cannot be automatically validated.
1.Claims are flagged for further review per Medicaid policy and then HMS determines what documentation is required to determine if an improper payment exists and/or the amount of the improper payment.
2.On-site audit/Desk review if necessary
3.Documentation is requested from the provider or appropriate party and reviewed to determine if an improper payment exists
4.Additional documentation is reviewed if provider chooses to submit.
5.After the review process is completed, result letters are sent to providers. The letters communicate:• Detailed description of final determinations • Improper payment amount • Recovery process• Option to appeal
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Virginia Medicaid RAC ProtocolComplex Review Provider response to Initial Records Request letter: 15 calendar days
Provider response to preliminary Finding of Facts letter: 30 calendar days to submit additional documentation for review.
HMS issues Final Audit report. If additional documentation is provided for consideration, HMS issues Final Audit report after re-review.
Provider response to Final Audit report: 30 calendar days to appeal from receipt of Final Audit report as required by Virginia Administrative Code.
If provider agrees or fails to respond to Final Audit report, HMS notifies Virginia DMAS and recoupment efforts will begin.
If provider disagrees, they appeal directly to DMAS’ Appeal Division and DMAS will verify the date the appeal was received and send HMS the date and time a case summary must be completed. Provider may have case heard by written submission or can request an in person IFFC (Informal Fact Finding Conference).
If the provider appeals no recoupment efforts will take place until the appeal process is completed and a final decision has been rendered.
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Virginia Medicaid RAC Appeals ProcessAppeals
HMS will follow the current Virginia appeal process:
• HMS has a concentrated effort to assure that result letters are detailed and specific, which helps to reduce the burden of appeal on all parties
• Providers are encouraged to call HMS’ toll free number to discuss and resolve administrative issues
• Call volume is monitored to identify issues and create educational sessions that focus on those issues
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HMS Audit Support
HMS’s Provider Relations staff are practiced at establishing and maintaining effective
communication with providers and strives to resolve provider issues on the first call
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Focused Provider RelationsOutreach
• Inform providers on upcoming events including RAC processes and communication protocol
• Attend provider association meetings
• Develop appropriate communications through webinar, VA-RAC website (http://va.dmas.medicaid-rac.com), HMS RAC website and newsletters
Transparency• Schedule of events and upcoming audits
• Broadcast modifications to process and procedures
Education• Recommendation to providers for resolving each issue scenario
• HMS staff available to assist with issue resolution
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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 PortalSecure 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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Wrap Up, Next Steps, Questions
Contacts
• Erik ChaseProgram [email protected]
• Joleen Bond-LivingstonVice President, Recovery [email protected]
• Kathy LippmanExecutive [email protected]
• Allee PontonContract Monitor – DMAS