Slide 1 - 2011 Minnesota Age and Disabilities Odyssey by zhangyun

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									THERE ARE
  AUDITS

        & THEN
       THERE IS

                                   PERM !

            2011 Odyssey 6/20/11        1
        Presented at the
2011 Age and Disabilities Odyssey
          Conference
         June 20, 2011
        Rochester , MN
           2011 Odyssey 6/20/11     2
   Presented By:


 Christina Baltes, RN, BSN, PHN, MA.
Manager, Program Compliance and Audits
  Internal Audits-Office of Compliance
  MN Department of Human Services
  Email: christina.baltes@state.mn.us
       Direct Line: 651-431-4279
               2011 Odyssey 6/20/11      3
       TODAY’s OBJECTIVES
   Understand the current types of audits
    conducted by the Centers of Medicare and
    Medicaid (CMS)
   Have an understanding on how to prepare
    for these audits
   Gain an understanding on how to avoid
    errors with fiscal penalties


                  2011 Odyssey 6/20/11     4
                     Acronyms
   CDCS-Consumer Directed Community Supports
   CHIP- Children's Health Insurance Program
   CHIPRA-Children's Health Insurance Program
    Reauthorization Program
   CMS – Centers for Medicare and Medicaid Services
   DDC-Documentation/Database Contractor
   DP- Data Processing [Claims Processing]
   DRG – Diagnostic Related Group
   DRA-Deficit Reduction Act of 2005
   DT&H-Day Training and Habilitation
   FFS-Fee for Service
   FFY-Federal Fiscal Year
   FQHC-Federally Qualified Health Centers
   FFP-Federal Financial Participation
                       2011 Odyssey 6/20/11            5
                     Acronyms
   HHA-Home Health Agency/Home Health Aide
   HCPCS-Healthcare Common Procedure Coding System
   HHS-The Department of Health and Human Services
   ICF- Intermediate Care Facilities (ICF/MR-per Federal
    Regulation 42 CFR 483 Subpart I)
   IEP-Individual Education Plans
   IPERA-Improper payments Elimination And Recovery Act
    of 2010
   IPIA – Improper Payments Information Act of 2002
   IPP-Individual Program Plan
   ISP-Individual Service Plans
   IHP-Individual Habilitation Plans
   LON-Level of Need
                           2011 Odyssey 6/20/11           6
   LTC-Long Term Care
                    Acronyms
   MAXIS- DHS recipient eligibility system
   MDS-Minimum Data Set
   MEQC-Medicaid Eligibility Quality Control
   MIC-Medicaid Integrity Contractor
   MIP-Medicaid Integrity Program
   MMIS – Medicaid Management Information System
   MSIS - Medicaid Statistical Information System
   MR-Medical Review
   NH-Nursing Home
   NPRM-Notice of Proposed Rule Making
   OASIS- Outcome and Assessment Information Set
   OMB-Office of Management and Budget
                      2011 Odyssey 6/20/11           7
                    Acronyms
   OIG: Office of Inspector General
   PA-Prior Authorization or Physician’s Assistant
   PAM – Payment Accuracy Measurement
   PAR-Performance and Accountability Report
   PERM – Payment Error Rate Measurement
   PEPPER-Program for Evaluating Payment Patterns
    Electronic Report
   SCHIP – State Children’s Health Insurance Program
   SMERF – State Medicaid Error Rate Findings
   SSA-Social Security Act
   SSI-Supplemental Security Income
   SSDI-Social Security Disability Insurance
   WIC-Western Integrity Center (similar to RAC)
   ZPICs: Zone Program Integrity Contractors
                       2011 Odyssey 6/20/11             8
Hot Topic-Payment Accuracy
   “Improper payments” occur when funds go
    to the wrong recipient, the recipient
    receives the incorrect amount of funds
    (including overpayments and
    underpayments), documentation is not
    available to support a payment, or the
    recipient uses funds in an improper manner.
   Fiscal Reporting Year 2009-HHS $66.4
    Billion “Improper Payments.”
   Website: http://www.paymentaccuracy.gov/
                     2011 Odyssey 6/20/11         9
Today’s Objective #1


   Understand the
   current types of
 audits conducted by
    the Centers of
    Medicare and
   Medicaid (CMS)
      2011 Odyssey 6/20/11   10
FEDERAL AUDITS


      How many
      federal audits
      are there for
      health care
      providers?
    2011 Odyssey 6/20/11   11
ANSWER




 2011 Odyssey 6/20/11   12
MEDICARE : Comprehensive Error Rate Testing
•First error rate reported in November 2003
•Calculates a national paid claims error rate for
the MC Fee-For-Service
•Random selection of claims submitted for MC
payment-records requested and reviewed
•Overpayments are collected from Providers
•FY 2009-Total Dollars paid $308B-7.8% error rate
($24.1 B) up from 3.6% in 2008-highest category
DME 51.9%
        http://www.cms.hhs.gov/CERT/
                     2011 Odyssey 6/20/11           13
CERT Top Three Error Reasons
  • Records from the treating physician not
            submitted or incomplete
• Missing evidence of the treating physician's
        intent to order diagnostic tests
 • Missing or illegible signatures on medical
             record documentation

http://www.cms.gov/CERT/Downloads/CERT_R
                  eport.pdf


                 2011 Odyssey 6/20/11            14
  Medicare: Recovery Audit Contractor (RAC)

•3-year Demonstration project- 2005 to 2008
•States impacted: NY-MA-FL-SC-CA
•$1.3 billion in errors found
•Provider appeals as of 2008: 14% appeal
•Overturned 4.6%
•RAC Permanent-all states beginning 2011 -
Section 302 of the Tax Relief and Health Care Act
of 2006
           •http://www.cms.hhs.gov/RAC
                      2011 Odyssey 6/20/11          15
                RAC Readiness



•Know where previous improper payments have
                been found
•Know if you are submitting claims with improper
                   payments
     •Prepare to respond to RAC additional
           documentation requests
                •Do self audits!
         http://www.cms.hhs.gov/RAC
                   2011 Odyssey 6/20/11            16
         Other Federal Audits for
           Medicare/Medicaid
Office of Inspector General (OIG):
• Public Law 95-452:protect the integrity of
   HHS programs.
   http://oig.hhs.gov/organization.asp

Centers for Medicare and Medicaid (CMS)
• CMS Strategic Action Plan Objectives:
  Accurate and Predictable Payments
  http://www.cms.gov/MissionVisionGoals/
                   2011 Odyssey 6/20/11        17
Medicaid : Comprehensive Medicaid Integrity
               Program (CMIP)
• CMIP is the result of the Deficit Reduction
  Act of 2005.
• Medicaid Integrity Program (MIP)-
  developed with a goal to prevent Fraud,
  waste and abuse.
• Section 1936 of the SSA-CMS procures 3
  types of Medicaid Integrity Contractor
  (MICs)

                  2011 Odyssey 6/20/11      18
Medicaid : Comprehensive Medicaid Integrity
        Program (CMIP) continued….
• Review MICs: Analyze MA Claims
• Audit MICs: Conducts audits to identify
  overpayments-States collect $ from
  Providers
• Education MICs: Educate Providers
• Started in 2010 in Minnesota
• MDHS-Surveillance and Integrity Review
  Unit-Ron Nail-ron.nail@state.mn.us (Do not
  include PHI)
• https://www.cms.gov/ProviderAudits/
                 2011 Odyssey 6/20/11    19
Medicaid: Review Audit Contractor (RAC)
 • Created by the Affordable Care Act
 • Target implementation date 2011 (???)
 • Proposed Rule FR Vol. 75, No. 217
   (11/10/10)
 • MDHS responsible for MA RAC in
   Minnesota-Surveillance and Integrity
   Review Unit-Ron Nail, Manager
   ron.nail@state.mn.us (Do not include PHI)
 •   https://www.cms.gov/RAC/
                 2011 Odyssey 6/20/11      20
           Other Auditing Entities
                for Medicaid

• Office of Inspector general (OIG)

• Centers for Medicare and Medicaid (CMS)

• Office of the Legislative Auditor (OLA)

• State Auditor’s Office (Single Audits)
                   2011 Odyssey 6/20/11     21
         WAIT!!! HOLD IT!!



THERE IS ONE
   MORE!!


        2011 Odyssey 6/20/11   22
Did you                       Oh No!
 hear                         Another
 that?                         Audit!




                AHHHHHH!
          NOT A ANOTHER AUDIT!



                2011 Odyssey 6/20/11    23
            Medicaid- PERM
   PERM – Payment
    Error Rate
    Measurement

   An audit for Medicaid
    and State Children’s
    Health Insurance
    Program

                  2011 Odyssey 6/20/11   24
    Why was PERM developed?
   IPIA (Improper Payment Information Act of 2002)
    & amended in July 2010 by Improper Payments
    Elimination and Recovery Act (IPERA).
   IPERA amended IPIA to:
    – Improve agency efforts to reduce and recover improper
      payments
    – Assess program for risk of making improper payments;
      estimate and report these amounts annually; and take
      corrective actions.
    – Expanded the types of programs that are required to
      conduct payment recovery audits
    – Authorized agency heads to used recovered funds for
      additional uses
    – Defined actions to be in compliance and actions if not in
      compliance          2011 Odyssey 6/20/11                25
                Regulations
   August 27, 2004 (Federal Register Vol. 69 No
    166): PERM Proposed Rules
   October 5, 2005 (Federal Register Vol.70 No
    192 ): PERM Interim Rule
   May 16 2006 (Federal Register Vol. 71 No 94):
    Proposed New System of Records-Privacy Act
    of 1974
   August 28, 2006 (Federal Register Vol. 71 No
    166): PERM Interim Final Rule
   August 31, 2007 (Federal Register Vol. 72 No
    169): PERM Final Rule effective October 1,
    2007              2011 Odyssey 6/20/11          26
              Regulations


   July 25, 2008 (Federal Register Vol. 73 No
    144): PERM Modification of Data Collection
   CHIPRA 2009 signed 2/4/09 effective 4/1/09
    (pub Law 111-3)-modifications of process
   Final Regulations-August 11, 2010 Federal
    Register Vol. 75, No. 154
   Improper Payments Elimination And Recovery
    Act (IPERA) 7/22/2010
                  2011 Odyssey 6/20/11    27
PERM Final Rule Changes
Sample size - claims and eligibility – Maximum set at
1,000 Beginning in FY 2011, state-specific sample sizes
will be calculated based on the prior year’s component-
level error rates

Review process – medical necessity reviews
Providers must submit documentation within 75 days

Difference resolution – claims and medical necessity
States can now appeal errors below $100

Difference resolution – claims and medical necessity
States now have 20 business days to request a
difference resolution and 10 business days to request an
appeal to CMS            2011 Odyssey 6/20/11              28
          Authority to establish
               regulations

   Sections 1102 (a) of the SSA
   Medicaid Statute Section 1902(a)(6) and
    CHIP statute Section 2107(b)(1) of the
    SSA-States Provide Information
   SSA Section 1902 (a) (27) and 42CFR
    457.950 –Providers to submit
    information for claims and payments
                  2011 Odyssey 6/20/11        29
PERM Program Structure




       2011 Odyssey 6/20/11   30
        PERM Program Structure
   CMS
   Contractors
    – Statistical
    – Documentation
    – Review
   State Medicaid Staff
   State Service Partners (e.g.
    Providers, Counties, etc.)
                   2011 Odyssey 6/20/11   31
PERM AUDIT
  CYCLES




  2011 Odyssey 6/20/11   32
                           PERM CYCLE ONE


                                                  FFY 2006/2009/2012:
                                  Pennsylvania, Ohio, Illinois, Michigan
                           Missouri, Minnesota, Arkansas, New Mexico,
                           Connecticut, Virginia, Wisconsin, Oklahoma,
•Everest Region Nepal 99       North Dakota, Wyoming, Kansas, Idaho,
                                                               Delaware

         Note: From FFY 2009 PERM measures FFS, Managed
                  Care, and Eligibility for MA and CHIP.

                                2011 Odyssey 6/20/11               33
                     PERM CYCLE/YEAR
                       TWO & THREE

   FY 2007/2010/2013: North Carolina, Georgia,
    California, Massachusetts, New Jersey, Tennessee,
    West Virginia, Kentucky, Maryland, Alabama, South
    Carolina, Colorado, Utah, Vermont, Nebraska, New
    Hampshire, Rhode Island

   FY 2008/2011/2014: New York, Florida, Texas,
    Louisiana, Indiana, Mississippi, Iowa, Maine, Oregon,
    Arizona, Washington, District of Columbia, Alaska,
    Hawaii, Montana, South Dakota, Nevada


                            2011 Odyssey 6/20/11            34
How Does PERM
    Work?




        2011 Odyssey 6/20/11   35
   Multiple Component Areas
Three distinct components for each Fee for
  Service Program (MA & CHIP) = 6 audits
 Claims Processing

 Medical Necessity

 Recipient Eligibility

One distinct component for each Managed
  Care Program (MA & CHIP) = 2 audits
 Claims Processing

                2011 Odyssey 6/20/11         36
           Perm Review Areas
   Claim Processing

    Involves:
    Medicaid Fee For Service
    Medicaid Managed Care
    CHIP Fee For Service
    CHIP Managed Care

    Any services paid for by Title 19
    and 21 funds-includes waiver services.
                     2011 Odyssey 6/20/11    37
          Perm Review Areas
   Medical Necessity

Involves:
  Medicaid Fee For Service
  CHIP Fee For Service

    Any services paid for by Title 19 and 21
    funds-includes waiver services.
                   2011 Odyssey 6/20/11        38
         Perm Review Areas
Recipient Eligibility

Involves all new applicants,
  redeterminations, on-going, denied and
  closed/terminated recipients for all Title 19
  (MA) and 21 (CHIP) for the audit Federal
  fiscal year.


                   2011 Odyssey 6/20/11       39
Claim Processing And Medical
          Necessity

         First Steps


          2011 Odyssey 6/20/11   40
PERM Claims and Medical Review
     Component Process

  Statistical Contractor
    conducts quality
   control on FFS and                        Documentation/Database
     managed care                                   Contractor
  universes submitted                          collects policies from
      by states and                             states and medical
     selects random                           records from providers.
      samples from
  universes for review.




                            Review Contractor
                             performs medical
                           and data processing
                               reviews and
                            conducts difference
                              resolution with
                                  states.
                           2011 Odyssey 6/20/11                         41
    What is a Claim for
    PERM Purposes?
   Depends on the program’s payment method
   PERM sampling unit: smallest, individually
    priced unit paid for a single beneficiary
   For example
     – State pays professional services by line item:
       The line item is the sampled unit
     – State pays inpatient hospital claims by DRG
       or per diem: The DRG or per diem rate (claim
       header) is the sampled unit
                      2011 Odyssey 6/20/11              42
Anticipated Categories for MN 2012
              20 Categories!
   Category 1:   Inpatient Hospital Services
   Category 2:   Psychiatric, Mental Health &
                  Behavioral Health Services
   Category 3:   Nursing Home, Convalescent
                  Centers, ICF, ICF/DD (Federal
                  Terminology at 42 CFR 483
                  Subpart I ICF/MR) & Chronic
                  Care Hospitals
   Category 4:   Outpatient Hospital Services, ER,
                  Practitioners and Clinics
   Category 5:   Dental & Oral Surgery Services
                     2011 Odyssey 6/20/11         43
    More anticipated 2012
         Categories
   Category 6:    Prescribed Drugs
   Category 7:    Home Health Services (HHA/
                   Supplies/ equipment/ appliances via HHA)
   Category 8:    Personal Support Category (PCA/Respite
                   Care/Homemaker/TCM/Private Duty
                   Nursing/Nurse Midwife/Meal Delivery)
   Category 9:    Hospice Services
   Category 10:   Therapies, Hearing and
                   Rehabilitation Services
   Category 11:   Habilitation and Waiver
                   Programs, Adult Day Care and
                   Foster Care
                      2011 Odyssey 6/20/11             44
    Even more anticipated
      2012 Categories
   Category 12:   Laboratory, X-Ray and Imaging
                   Services
   Category 13:   Vision, Ophthalmology,
                   Optometry and Optical Services
   Category 14:   Durable Medical Equipment
                   (DME) and supplies Prosthetic /
                   Orthopedic devices, and
                   Environmental Modifications
   Category15:    Transportation and
                   Accommodations
                     2011 Odyssey 6/20/11            45
    The rest of the anticipated
        2012 Categories
   Category 16:   Denied Claims
   Category 17:   Cross-over Claims
   Category 30:   Capitated Care / Fixed Payments
                   Capitated Payments to Primary
                   Care Case Management (PCCM)
                   Medicare Part A Premiums
                   Medicare Part B premium
                   Health Insurance Premium
                   Payments (HIPP)
   Category 50:   Managed Care
   Category 99:   Unknown (Claim data individually
                   reviewed to determine category)
                        2011 Odyssey 6/20/11          46
 2012 Predicted Components &
         Sample Sizes
Medicaid
 •FFS: 500 line items

 •Managed Care: 250 capitation payments

 •Eligibility: 504 active cases, 500+ negative
  cases
CHIP
 FFS: 500 line items

 Managed Care: 250 capitation payments

 Eligibility: 504 active cases, 200 negative
  cases              2011 Odyssey 6/20/11      47
        PERM
       CLAIMS
     PROCESSING




2011 Odyssey 6/20/11   48
     FFS, Managed Care & CHIP
     Claims Processing Reviews
   Done by CMS contractors
   Onsite in MN
   Onsite usually one week long per Quarter
   Review sample to determine improper payments
   Looks at all aspects of claims processing




                    2011 Odyssey 6/20/11       49
         PERM
Medical Necessity Review




        2011 Odyssey 6/20/11   50
    PERM Medical Necessity Review
   Done offsite
   Smaller Sample than Data Processing
   Documentation collected by CMS’s
    Contractor from Providers DIRECTLY
   Providers submit documentation to support the service
    that was rendered on the service date billed
           All documentation required as per DHS Policy,

                                  Provider Manuals & State
                                           and Federal laws



                        2011 Odyssey 6/20/11              51
          PERM
Recipient Eligibility Reviews




         2011 Odyssey 6/20/11   52
    PERM Recipient Eligibility Review

   Purpose: to identify improper payments based
    on erroneous eligibility determinations.
   Done on-site by DHS staff in Program
    Compliance and Audits
   Review all criteria for Medicaid and CHIP
    eligibility
   Results in a payment error if received services
    and not eligible for MA or CHIP


                     2011 Odyssey 6/20/11             53
                                                 3
Today’s Objective # 2

    Have an
understanding on
how to prepare for
  these audits


      2011 Odyssey 6/20/11   54
          Train The Staff!!!

•   Provide the service correctly
•   Document the service
•   Bill correctly
•   Audit your records



               2011 Odyssey 6/20/11   55
      Do Quality Control for Claim
             Processing
   Check # of units billed
   Check diagnoses
   Check billing code
   Check service dates-are the dates being
    entered the correct dates of service?
   Do you have a prior authorization for the
    service (if needed)?
     Randomly select claims and
          review them!!!
                   2011 Odyssey 6/20/11         56
    Do Quality Control on the Medical
                Records
   Randomly select records and compare the
    documentation to the required regulations,
    policies and procedures
   Does the documentation reflect the service
    provided?
   Are the required forms in the record?
   Does the documentation match the
    HCPCS code billed?
   ICD 10 Anyone?? Prepare!
                   2011 Odyssey 6/20/11      57
 Provide the service you are
       authorized for!!


   Do you have the correct
  License, Certification, Prior
    Authorization and are a
registered provider with DHS?
            2011 Odyssey 6/20/11   58
          PROVIDER LICENSE
                  Provider enrollment unit.
  When sending in your license in please include a note
that states that this is your current license from MDH (or
 the pertinent licensing authority) and include a contact
               person and your NPI/UMPI.

      Minnesota Department of Human Services
              Provider Enrollment Unit
                  P.O. Box 64987
             St. Paul, MN 55164-0987
                FAX: (651) 431-7462
                       2011 Odyssey 6/20/11           59
Today’s Objective # 3

      Gain an
 understanding on
how to avoid errors
  and subsequent
  fiscal penalties!

      2011 Odyssey 6/20/11   60
  HOW????

Find out what the
    auditors are
  looking at and
   what they are
    looking for?


     2011 Odyssey 6/20/11   61
    Claim Processing Review-Some
                Hints
   Duplicate claim item?
   Covered service?
   Service covered by HMO?
   Third Party Liability?
   Logical edits (i.e. gender conflict e.g. (male birth/
    provider conflict-excluded providers)?
   Data entry errors?
   License/Registration/Certification current?
   Procedure Coding Error
   Unbundling of services
                         2011 Odyssey 6/20/11               62
  What kinds of PERM “data
 processing errors” are there?

DP1 Duplicate item
DP2 Non-covered service
DP3 FFS claim for a Managed care service
DP4 Third-party liability:
DP5 Pricing error.
DP6 Logic edit
DP7 Data entry error
DP8 Rate Cell error
DP9 Managed Care payment error
DP10 Administrative/Other
               2011 Odyssey 6/20/11        63
Medical Review-Some Hints
  Was all documentation submitted?
  Does the documentation support the service
    provided?
  Required forms, etc. in the record
  Was the service medically necessary?
  Does the documentation support the
    procedure code billed?
  Is the diagnosis correct?
  Was there a Policy violation
  Unbundling of services
               2011
  Number of unit Odyssey 6/20/11
                    (s) error             64
                           Pay
                       attention to
                       the Audit’s
                       Request for
                        Records



2011 Odyssey 6/20/11              65
           Is there one person
     responsible for collecting the
                information?
        Is it your Compliance or
      Quality Assurance Officer?
          Is there a back-up for
          vacations or illnesses
     Does the person understand
       what is being requested?
      Call PERM with questions
       before a mistake is made!
     Work with your State Contact
           for the other audits!
2011 Odyssey 6/20/11            66
   PERM Medical Record
       CAUTION
      Request for additional
        documentation!
Reasons: Initial submission lacked
    complete documentation
         Quality Control
           2011 Odyssey 6/20/11   67
             Medical Review More Hints!
   Long list for each Category-read them carefully!
   Information requested does not always apply
   Different Terminology/Words/Acronyms
   Goes beyond the date/s of service
   One “T” not crossed = error
   Multiple requests-confusing to provider
   Watch Time Frames!!
                     2011 Odyssey 6/20/11              68
Medical Review Some More Hints!
   Mailing records no follow-up
   Therapy Notes not sent with record
   Inaccurate documentation
   Lack signatures/dates/times
   Leave of Absence-documentation leaving and
    return
   Medical Necessity documentation lacking
   Watch Dates of Service!!
                     2011 Odyssey 6/20/11        69
    Medical Review Lessons Learned

   Medical Records/Staff not aware what to send
   Time frames for the audits-PERM 75 days and
    14 days
   One day late = error
   Documents copied or sent by Fax can’t be read
   Fax confirmation not saved or no follow-up



                     2011 Odyssey 6/20/11           70
    Medical Review Lessons Learned
   Address or contact person not current with
    DHS-call Provider Enrollment!
   Facility or recipient name change
             If item is not applicable-write N/A
             and indicate on the bar code page
              that N/A is NOT APPLICABLE -
             Why? So that CMS does not think
            that the document is “not available”
                   2011 Odyssey 6/20/11       71
     Medical Review Issues to avoid!
   MDS-ISP-IPP-IHP-OASIS Assessments Not
    Documented
   MDS-ISP-IPP-IHP-OASIS - correct dates
    not sent / not signed
   Physician’s Order – correct dates
   Physician Certification-correct dates/ TO/VO date
   Physician Visits (MD-NP-MD)
   Physician Signature-lacking
   MD signed Recap Order Dates Outdated
   Adding of orders after MD signs in the area above
    MD’s signature        2011 Odyssey 6/20/11          72
PERM Medical Review “error”
         Types
  MR1 No documentation
  MR2 Insufficient documentation
  MR3 Procedure coding error
  MR4 Diagnosis coding error
  MR5 Unbundling
  MR6 Number of unit (s) error
  MR7 Medically unnecessary
        service
  MR8 Policy violation
              2011 Odyssey 6/20/11   73
  MR9 Administrative/Other
    The DHS Health Care Programs
          Provider Manual
   Available at http://www.dhs.state.mn.us
   Provides instructions to Providers on
    minimum program requirements
   Provider Manual Questions Call Provider
    Help Desk at 651-431-2700
   PERM questions call me at 651-431-
    4279


                  2011 Odyssey 6/20/11        74
      PERM
Eligibility Reviews




    2011 Odyssey 6/20/11   75
  PERM Eligibility Component Process
Eligibility component has four phases:
   1. Sampling
   2. Eligibility Reviews
   3. Payment Reviews
   4. Error Rate Calculation
   Eligibility component has four stratum:
      1. New Applications
      2. Redeterminations
      3. All Other Current Recipients
      4. Negative Case Action-Denied/Closed
                       2011 Odyssey 6/20/11   76
  Oh No!
What do you
  mean
“ERROR?”

         2011 Odyssey 6/20/11   77
2011 Odyssey 6/20/11   78
 APPEAL???

   Most Audits have a process!
For PERM there are several steps:
   1) MDHS to CMS Contractor
         2) MDHS to CMS
  3) MDHS to HHS Department
          Appeals Board
       4) Provider to MDHS


     2011 Odyssey 6/20/11    79
      What Happens when there is a
    PERM “error” for claims and medical
                  review?
   State PERM Director/Manager Notified
   Time sensitive gathering of information
   File Difference Resolution to contractor if
    appropriate-20 business days
   If successful-error reversed by contractor
   If denied appeal to CMS
   CMS has final say!!

                       2011 Odyssey 6/20/11       80
              Error Impact PERM……
   Claims and Medical Reviews
    – Reimburse CMS and collect from Provider
   Eligibility Errors
    – Regulation does require payment to CMS.
   Fraud Referrals as appropriate
   PERM HAS FINANCIAL IMPLICATIONS
   PAY CMS $$$ BACK



                         2011 Odyssey 6/20/11   81
  PERM Corrective Action Plan
           Analyze “errors!”

  Develop and implement a corrective
              action plan.

 Providers/Partners with errors will be
   asked for a corrective action plan!

Corrective Action Plan submitted to CMS

Plan implementation crucial as it will be
    “tested” at the next PERM cycle
                   2011 Odyssey 6/20/11     82
Minnesota Versus National
  Results and Findings




         2011 Odyssey 6/20/11   83
   PERM FINDINGS NATIONAL

MEDICAID 2006 FFS ONLY– 4.7%
     MEDICAID 2007- 10.5 %
 • FFS 8.9 % Managed Care 3.1%
           Eligibility 11%
     MEDICAID 2008 – 8.7 %
• FFS 2.6 % Managed Care 0.1%
         • Eligibility 6.7%
        CHIP 2007 14.7%
• FFS 11.0 % Managed Care 0.1%
        • Eligibility 11.0%
         2011 Odyssey 6/20/11    84
          MEDICAID 2009
        Overall National 8.98%
             FFS 1.89 %
         Managed Care 0.13%
           Eligibility 7.6%

           MINNESOTA 2009
            Overall 2.00%
              FFS 0.55 %
          Managed Care 0.00%
            Eligibility 1.64%
2011 Odyssey 6/20/11         85
Medicaid FFS Medical Review Percentage
   of Dollars in Error by Service Type
                                                   Durable Medical
                                                Equipment (DME) and
                                                supplies, Prosthetic /
                                               Orthopedic devices, and
                                                    Environmental
             Habilitation and Waiver                Modifications
           Programs, Adult Day Care                    0.77%
                and Foster Care
                       5.97%




                                                                         Home Health Services
                                                                               49.63%




 Personal Support
     Services
     43.63%



                                       2011 Odyssey 6/20/11                                     86
             Medical Reviews
              •Medicaid FFS Medical Review
             Percentage of Dollars in Error by
                       Error Type
   •Dollar                                      Insufficient
                                              documentation
                Administrative/other
   Errors             5.97%
                                                  1.51%


•2006 was
   About
 •$18, 000

•2009 was
  •about
 •$5,000
                                                 Number of unit(s) error
                                                      92.52%
                       2011 Odyssey 6/20/11                                87
FY 2009 PERM MA High Level
         Findings
 Medical Review
 – Federal
 – Diagnosis Coding
 – Insufficient Documentation
 – Number of Units

 State
   • Insufficient Documentation (14.3 %)
   • # of Units Error (71.4%)

               2011 Odyssey 6/20/11        88
FY 2009 PERM MA High Level Findings
  Data Processing
  Federal
     • Duplicate Items
     • FFS Claim for a Managed Care Recipient
  State
     None (Keep it up!)
  Managed Care
     Federal
     • Non Covered Service
     • Duplicate Items
  State
     None (Keep it up!)
                   2011 Odyssey 6/20/11         89
Remember- we are all on the
      same team!




         2011 Odyssey 6/20/11   90
      The Spirit of
      Cooperation

  The concept of “US”
 We work together as a
     team to carry out
  DHS’s Mission and to
    assist our citizens!

         2011 Odyssey 6/20/11   91
     Urgh!!                              Call Me-
    TMI-TMI-                            Let’s work
     TMI !                               together
                                        and assist
                                        each other!




Use DHS Resources-Call
651-431-4279
Provider Help Desk-
Resource Specialists,
Manual, etc.     2011 Odyssey 6/20/11                 92
               PERM Resources


   Check the DHS website:
      http://www.dhs.state.mn.us

   Check the CMS website:
      http://www.cms.hhs.gov/PERM

   Call Christina Baltes at 651-431-4279
                 2011 Odyssey 6/20/11   93
Thoughts
                                  Questions?
 hmm..




                                  Comments!



           2011 Odyssey 6/20/11           94

								
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