Section 6411 of the Affordable Care Act, Expansion of Recovery Audit Contractor (RAC) Program, amends section 1902(a)(42) of the Social Security Act and requires states to contract with a RAC vendor and allows states to reimburse contractors who assist in the identification and recovery of improper payments.
Missouri contracted with Cognosante, LLC in December, 2011 to serve as Missouri’s RAC.
Also, as part of the Deficit Reduction Act of 2006, the Medicaid Integrity Program was established. This program utilizes Medicaid Integrity Contractors (MICs) to analyze Medicaid claims data to identify high-risk areas and potential vulnerabilities, as well as conduct post-payment audits.
Missouri’s MIC is Health Integrity, LLC. The MICs are assigned by geographic location.
Both the RAC and the MIC may utilize subcontractors. A list of the contractors’ and subcontractors’ names is located below. Should you receive any communication from an entity representing itself on behalf of Missouri Medicaid Audit and Compliance (MMAC), or one of the companies listed below, and you are concerned about the legitimacy of the person or company, you should contact MMAC at (573) 751-3399 to verify the communication or request is legitimate.
Currently, Missouri’s MIC is conducting audits of Missouri hospice providers. The MIC may request documentation that supports Medicaid-enrolled participants’ eligibility for hospice, and other documents to ensure proper billing.
The Missouri RAC is preparing to conduct audits of enrolled Missouri pharmacy providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing) and that proper quantities were billed. They may request documentation to include items such as a copy of the original prescription, the dispensing record, documentation of offer to counsel, and the signed delivery record.
The RAC is also preparing to conduct audits of enrolled Missouri durable medical equipment providers. The RAC will be reviewing paid claims for proper billing, and to ensure the claims were not paid twice (duplicate billing). They may request documentation to include items such as precertification and prior authorization forms and supporting documentation, prescriptions, physician’s orders, invoices, proof of delivery, and certificate of medical necessity.
Medicaid Integrity Contractor (MIC): Health Integrity, LLC
Recovery Audit Contractor (RAC): Cognosante, LLC
RAC Subcontractors:
Recovery Audit Specialists LLC
CDR Associates
Missouri Regulation 13 CSR 70-3.020 (7) requires providers to inform the state of any changes affecting their MO HealthNet enrollment records. These changes, including change of address, are to be reported by the provider on specific forms within 90 days of the change (except for change of ownership or control, which must be reported within 30 days). In addition, section 2.2 of the MO HealthNet Provider Manual requires providers to notify the Provider Enrollment Unit (PEU) of a change of address.
In Missouri, these updates and changes are reported to the PEU at Missouri Medicaid Audit and Compliance (MMAC).
In accordance with the regulation above, the PEU at MMAC inactivates enrolled providers whose mail has been returned to MMAC or MO HealthNet as undeliverable. This action suspends providers’ claims for 180 days, during which time the claims are neither paid nor denied. If the provider does not submit an address update form to PEU by the end of the 180 days, the provider’s claims will then be denied. This is done to help ensure provider enrollment records are accurate. Upon receipt and processing of the required form for updates, provider numbers are reactivated by the PEU.
In order to update your address with Provider Enrollment, please submit a Provider Update Request form. If you know your enrollment has already been made inactive due to undeliverable mail, write RETURNED MAIL in the upper right hand corner of the Update Request form. This will alert Provider Enrollment staff to forward any mail that has been returned.
The complete regulation is located at https://www.sos.mo.gov/adrules/csr/csr.asp and the MO HealthNet Provider Manuals are located at https://mydss.mo.gov/mhd/provider-manuals.
