PHARMACY DRUG REBATE – SELF DISCLOSURES

April 27, 2016

The Deficit Reduction Act of 2005 (DRA) requires states to collect rebates for certain drugs.  In order to collect accurate data for the rebate process, all incorrectly billed pharmacy claims must be corrected in the Medicaid billing system so accurate drugs and quantities are reported.  Therefore, providers who wish to self-disclose incorrectly billed pharmacy claims to Missouri Medicaid Audit and Compliance (MMAC) are asked to not submit a check.

 

Instead, the claim number(s) (ICN) should be reported on the self-disclosure form along with a clear explanation of the error; MMAC staff will then correct the claim(s) in the billing system and the correction will show up as such on the corresponding Remittance Advice (RA).  Click here to access the self-disclosure form.  If you have any questions, please contact MMAC at mmac.providerreview@dss.mo.gov

LONG-TERM CARE FACILITY CREDIT BALANCE AUDITS

April 26, 2016

As reported in a previous gov.delivery message by Missouri Medicaid Audit and Compliance (MMAC), HMS will soon begin conducting credit balance audits on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and MMAC. Click here to view the original message and website post.

 

When your long-term care facility is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS.  MMAC will also notify the Missouri Health Care Association and LeadingAge Missouri.  Long-term care facilities can expect to begin receiving letter regarding the credit balance audits after May 1, 2016.

 

Long-term care facility audits will be Medicaid-specific, and will be “desk audits”, where HMS will request that you send them information.  This means HMS will not come on-site to conduct the audit.

 

Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.

 

HMS has prepared its initial schedule for long-term care facility audits.

 

Review Start Date Provider Name 6/1/2013 BLUFFS (THE) 6/1/2013 GIDEON CARE CENTER 6/1/2013 GOWER CONVALESCENT CENTER 6/1/2013 LAVERNA VILLAGE OF ST JOSEPH 6/1/2013 LUTHERAN SENIOR SERVICES 6/1/2013 MARY QUEEN AND MOTHER CENTER 6/1/2013 MILAN HEALTH CARE CENTER 6/1/2013 VILLA MARIE-A STONEBRIGDE COMMUNITY 6/1/2013 VILLAGES OF JACKSON CREEK, THE 6/1/2013 WESTWOOD HILLS HEALTH & REHABILITATION C

 

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

HOSPITAL CREDIT BALANCE AUDITS

April 14, 2016

 

As reported in a previous gov.delivery message by Missouri Medicaid Audit and Compliance (MMAC), HMS will soon begin conducting credit balance audits on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and MMAC. Click here to view the original message and website post.

 

When your hospital is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS.  MMAC will also notify the Missouri Hospital Association. Hospitals can expect to begin receiving letters regarding the credit balance audits after May 1, 2016.

 

Hospital audits will be Medicaid-specific, and may be desk audits, where HMS will request that you send them information; or, the audits may be completed on-site.

 

Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.

 

HMS has prepared its initial schedule for hospital credit balance audits.  Click here to view the schedule.

 

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

HOME AND COMMUNITY BASED SETTING REQUIREMENTS

April 12, 2016

What are Home and Community-Based Setting Requirements?

 

The Centers for Medicare & Medicaid Services (CMS) published a final rule to enhance the quality of Home and Community-Based Services (HCBS) and to provide protections for participants.  The rule, or “setting requirements” makes sure individuals receiving HCBS have full access to the benefits of community living and have the opportunity to receive services in the most integrated and still appropriate type of setting.

 

Missouri, like other states, is in a transition period, during which the state agencies will assess the HCBS programs, and the rules and regulations that govern the programs, to ensure services will be delivered in settings that meet the new requirements.

 

The Missouri Medicaid Audit and Compliance Unit (MMAC) is participating in the state’s transition plan and transition activities in the following ways:

 

MMAC conducted on-site visits of all the Adult Day Care and AIDS Waiver locations, and completed HCBS surveys with those providers.  You can access the report here.

 

 

MMAC will include the HCBS surveys in future pre-enrollment site visits and provider revalidation site-visits, for all HCBS providers.  This means MMAC personnel will go over the survey with you and give you the opportunity to ask questions and discover where you may need to make improvements in order to be compliant in the future when these requirements take effect.  The state is expected to promulgate rules that will require providers to be compliant with the new setting requirements.

 

MMAC will include the survey in future audits and investigations of HCBS providers to ensure we continue to monitor the locations for the new setting requirements as well. Auditors will provide you with the survey and go over it with you.  Investigators may be on-site in consumers’ and participants’ homes and will verify the services are being delivered in the most integrated and still appropriate setting.

 

MMAC will also provide education and information about the new setting requirements to all HCBS providers at Provider Update Training and Designated Manager Training.

 

MMAC is not citing any errors or violations at this time.  This is a transition time.  MMAC will give information about the new setting requirements and how to achieve compliance.  In the future, MMAC will inform providers about any new regulatory language that will require them to become compliant or face possible sanctions.

 

MMAC is also giving providers the opportunity to complete an annual self-assessment. In the future, MMAC will inform providers about any new regulatory language that will require them to complete the annual self-assessment or face possible sanctions.  Click here for the Annual Self-Assessment.

 

What else do providers need to know?

 

See below for links to the full content of the final rule, including all the requirements.  Some highlights:

 

Home and Community-Based settings will be expected to be integrated in the community, and support access to the greater community.

 

The HCBS setting should also provide opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources.

 

The HCBS setting should ensure the participant’s or consumer’s rights of privacy, dignity, respect, and freedom from coercion and restraint.

 

Participants and consumers should be able to have visitors at any time.

 

The setting should be physically accessible to the participants and consumers.

 

Additional Resources:

 

Click here to see a PowerPoint presentation of the final rule and the new requirements.

 

Click here to be directed to the MO HealthNet Division’s webpage where you can access the state’s Transition Plan, Transition Plan Summary, and Settings Analysis (see Alerts and Notifications).

 

Click here to see more information about Home & Community Based Services, including the final rule, and questions and answers at Medicaid.gov.

HMS TO CONDUCT CREDIT BALANCE AUDITS (CBA) AND LONG TERM CARE AUDITS (LTC) ON PATIENT ACCOUNTS

April 5, 2016

Credit balances on patient accounts occur for a variety of reasons.  For instance, providers sometimes receive duplicate payments, charges may be reversed, billing data may be incomplete, and third party liabilities may be incorrectly applied.  Providers routinely identify and refund these credit balances (overpayments), but sometimes the ability to refund the overpayment in a timely fashion is constrained by limited resources or imperfect information.  Sometimes, providers aren’t aware the overpayments exist.  Not all credit balances result in an overpayment, and out of those, not all require a refund; some simply require an adjustment.

 

HMS will soon begin conducting credit balance audits, on behalf of the Missouri Department of Social Services, MO HealthNet Division, (MHD) and Missouri Medicaid Audit and Compliance (MMAC).  When your hospital or nursing home is scheduled for an audit, MMAC will send a letter notifying you, before you receive any correspondence from HMS.  MMAC will also notify the Missouri Hospital Association, Missouri Health Care Association, and LeadingAge Missouri.

 

Nursing home audits will be conducted as “desk audits”.  This means that HMS will review the patient accounts off-site after receiving any necessary documentation from the nursing home.  These audits will be specific to Medicaid patients (participants.)

 

Hospital audits will be Medicaid-specific, as well.  Hospital audits may be desk audits, or they may be completed on-site.

 

Providers will all have the opportunity for an entrance and exit conference, and MMAC and HMS will provide contact information for any questions, comments, or concerns that providers may have.