PHARMACY REMINDER: OFFER TO COUNSEL AND SIGNATURE LOG

March 30, 2016

Missouri State Regulation requires documentation of a pharmacist’s offer to counsel, for all MO HealthNet participants’ prescriptions.  The regulation states, “Documentation of Offer to Counsel:  The pharmacist shall document for each MO HealthNet patient’s prescription in a uniform fashion, whether the offer to counsel was accepted or refused by the patient or the patent’s agent. “  Click here to read the regulation:  13 CSR 70-20.310(7).

 

Additionally, pharmacies must obtain the signature of the participant or his/her representative, and the relationship of the representative to the participant.  Participants living in long-term care facilities such as nursing facilities, ICF/MR facilities, and psychiatric residential treatment facilities are granted an exemption from this requirement.

 

The signature log serves as verification that the participant received the prescription dispensed.  One signature per prescription is required, and electronic signatures are acceptable.  Providers must make the signature log and offer to counsel available upon request by MO HealthNet or MMAC.  More information about signature log requirements is found in the MO HealthNet Pharmacy Manual.  Click here to access the manual.

 

Please contact Missouri Medicaid Audit and Compliance (MMAC) at MMAC.PROVIDERREVIEW@DSS.MO.GOV  if you have any questions

HCBS PROVIDERS: ANNUAL UPDATE MEETING MATERIALS

March 25, 2016

The 2016 Spring Session of the Annual Provider Update Meeting for Home and Community Based Providers (HCBS), hosted by Missouri Medicaid Audit and Compliance (MMAC) is scheduled for April 19, 20, and 21, 2016.  Click here for information about the meeting.

 

A new feature for providers has been added to the MMAC website at the location (link) above.  Copies of the meeting’s Power Point presentations and handout materials are posted to the website.  Providers may review the materials prior to the meeting, and make copies to bring with them if they choose.  The materials will not be handed out at the meeting in order to save resources, so please bring a copy with you if you wish to have it during the meeting.  The materials will be projected for viewing during the presentations.

 

If you have any questions, please contact MMAC at MMAC.IHSContracts@dss.mo.gov

PARTICIPANT LOCK-IN PROGRAM

March 16, 2016

Missouri Medicaid Audit and Compliance (MMAC) is responsible for reviewing Medicaid (MO HealthNet) participants who may be subjecting the Medicaid program to fraud, waste, and abuse due to mis-utilizing or over-utilizing some of their MO HealthNet benefits.  MMAC will review the number of physicians prescribing services to a particular participant, the number of pharmacies used by the participant to obtain prescriptions, the frequency of refills or overlapping prescriptions, the number of emergency room visits, and the services received by the participant. 

 

If a MO HealthNet participant is determined to by mis-utilizing MO HealthNet benefits, he or she can be restricted to a physician/clinic, pharmacy, or both, in accordance with 13 CSR 70-4.070.  This restriction is called “Locked In”.  The Lock-In program is also described in the MO HealthNet Physician Manual.

 

When a participant is “locked in” to a specific provider, the provider’s name and telephone number are identified on the internet, IVR, or point of service terminal used when verifying eligibility.  Payment for services for a “locked-in” participant will not be made to unauthorized providers, except for emergency services, and authorized referral services.  Emergency services must be supported by medical records documenting the emergency circumstances.

 

The designated (authorized) “lock-in” provider is responsible for the participant’s primary care and for making necessary referrals to other providers as medically indicated.  When a referral is necessary, the authorized physician must complete a Medical Referral Form of Restricted Participant (PI-118) and send it to the provider to whom the participant is referred. 

 

The referral forms are available on the MMAC website.  Click here to access the forms.

 

The referral is good for 30 days only from the date of service.  The Reason for Referral field should be completed on the form, and the form must contain the NPI (and taxonomy code if appropriate) of the authorized provider.  If the participant is locked into a clinic, use the clinic’s NPI (not the individual physician’s).  The form must be submitted by  the unauthorized provider via the internet at www.emomed.com, or mailed to Infocrossing Healthcare Services, P.O. Box 5900, Jefferson City, MO 65102.

 

Read more about the Participant Lock-In Program at the MMAC website.

 

RESIDENTIAL CARE FACILITY (RCF) AND ASSISTED LIVING FACILITY (ALF) AUDITS

March 11, 2016

RCFs  and ALFs enrolled with Missouri Medicaid (MO HealthNet) may receive payments for personal care services provided in the facilities.  Missouri Medicaid Audit and Compliance (MMAC) may conduct an on-site audit or a desk review to determine whether the services were properly documented and billed, and that providers were paid appropriately.   An on-site audit means MMAC auditors will conduct an on-site visit, and scan the needed documentation.  A desk audit means MMAC will request records be sent by mail, fax, or email, without coming on-site.  To view the complete MMAC Provider On-Site and Desk Audits Guidance and Reference Material, click here.

 

For an RCF or ALF audit, MMAC auditors will generally ask to see the following documentation:

 

The care plan (Web Tool print-out or LTACS) for each participant, that corresponds with the review period EVV (Telephony) is not required for RCFs or ALFs Any and all documents that support services billed for each participant, for dates of service in the review period.  These may be timesheets, calendars, call-in logs, service delivery logs, or any other documents deemed necessary to complete the review.  MMAC auditors know that some providers use different names for documentation, and will communicate with you if they feel something is missing. A service delivery log must include the participant’s name, date of service (including the year), documentation of tasks performed, and appropriate daily signatures Census records.  If there are no census records, the auditors will request the medication administration records or nurse’s notes for the time period being reviewed Documentation of appropriate employee background (screening) checks, and documentation of a Good Cause Waiver if required A list of all employees who provided services during the review period (complete name, address, date of hire, date of first client contact, and termination date if applicable) Documentation of authorized nurse visits

 

MMAC auditors will use the following statute, regulations, and provider manual while reviewing the billing and the documentation for compliance:

 

RSMo 192.2495.2 13 CSR 70-3.030 13 CSR 70-91.010 19 CSR 30-86.042 19 CSR 30-82.060 MO HealthNet Provider Manual for Personal Care 

 

ANNUAL PROVIDER UPDATE MEETING

March 11, 2016

Missouri Medicaid Audit and Compliance (MMAC) is holding the spring session of the 2016 Annual Provider Update Meeting for Home and Community Based Providers on April 19, 20, and 21, 2016.  The presentation runs from 10:00 a.m. to 3:00 p.m. each day.

 

You are not required to attend all three days.  Attend either the 19th, the 20th, or the 21st.

 

The meeting will be held at the Harry S. Truman State Office Building at 301 West High Street in Jefferson City, MO.  You can access the driving directions at the MMAC website by clicking here.