The Missouri Medicaid Audit and Compliance Unit (MMAC) wishes to remind providers about incentives that are “kick-backs” and therefore not allowed.
The federal Anti-Kickback Statute is a criminal law that prohibits health care providers in a federal health care program from offering to exchange, or actually exchanging, anything of value to reward someone for referring business. Medicaid is a state and federally funded program. Conviction for a single violation can result in a fine of up to $25,000 and imprisonment. With or without a conviction, individuals may still be excluded from federal health care programs.
Missouri state regulation also prohibits these types of incentives. It is a violation to make any payment to any person for referring someone for goods or services, when MO HealthNet is providing payment. MMAC has received notice of providers offering incentives to MO HealthNet participants, and also offering incentives to employees to induce or refer participants. Providers may face sanctions for these practices.
The Missouri Medicaid Audit and Compliance Unit (MMAC) is responsible for reviewing participants who may be subjecting the Medicaid program to fraud, waste and abuse. This includes a review of a variety of factors which include:
The number of physicians prescribing services to a particular participant; The number of pharmacies used to obtain prescriptions; The frequency of refills or overlapping prescriptions; The number of emergency room visits, and The services received.
If a MO HealthNet participant is found to be misutilizing MO HealthNet benefits, the individual can be restricted to a physician/clinic, pharmacy, or both in accordance with 13 CSR 70-4.070, and may also be referred to the appropriate authorities for possible healthcare fraud investigation and prosecution.
If you suspect a participant is abusing Missouri Medicaid, you may report the suspicion to mmac.lockin@dss.mo.gov. It is helpful if you can provide the MO HealthNet participant’s name, Medicaid DCN, address, date of birth and/or social security number, and a complete description of the complaint. You can find further information regarding the Lock-In program at https://mmac.mo.gov/participants/participant-lock-in/
The Department of Social Services MO HealthNet Fee-For-Service Participant Handbook advises MO HealthNet participants of the following:
Committing MO HealthNet fraud or abuse is against the law. Fraud is a dishonest act done on purpose. Examples of participant fraud are:
Letting someone else use your MO HealthNet health insurance card Getting prescriptions with the intent of abusing or selling drugs Using forged documents to get services
Abuse is an act that does not follow good practices. Examples of participant abuse are:
Going to the emergency room for a condition that is not an emergency Misusing or abusing equipment that is provided by MO HealthNet Getting services from multiple providers of the same kind Trying to get more services than are necessary
Please submit any questions to MMAC.Lockin@dss.mo.gov
Missouri state regulation defines “adequate documentation” as documentation from which services rendered and the amount of reimbursement received by a provider can be readily discerned and verified with reasonable certainty. It is a program violation to fail to make available and disclose all records relating to services provided to MO HealthNet participants or records relating to MO HealthNet participants.
Documentation requirements for the MO HealthNet Behavioral Health Services program can be found here.
In addition, program requirements are detailed in the MO HealthNet provider manuals, found here.
The Missouri Medicaid Audit and Compliance Unit (MMAC) encourages all MO HealthNet Behavioral Health providers to review and be familiar with these program requirements, and to contact us at MMAC.ProviderReview@dss.mo.gov with any questions.
State and federal regulations (13 CSR 65-2 and 42 CFR 455.432) require pre-enrollment and post-enrollment site visits of providers who are designated as “moderate” or “high” categorical risks to the Medicaid program. The purpose of the site visits is to verify the information submitted to Missouri Medicaid Audit and Compliance (MMAC) is accurate and to determine compliance with federal and state enrollment requirements.
In July of 2015, MMAC began conducting pre-enrollment and post-enrollment site visits of new, reenrolling or revalidating providers assigned to moderate and high risk categories. Click here to see the risk category assigned to each Medicaid provider type in Missouri. If you are a “revalidating” provider that is assigned to a moderate or high risk category, you may receive notice of a site visit, although you might not have been subject to one in the past. MMAC personnel will conduct site visits during regular business hours, provide you with advance notice of the site visit, and will utilize another current regulatory site visit in lieu of conducting a redundant visit, when appropriate. As well, site visits conducted by Medicare or other state Medicaid agencies within the previous two years may suffice in place of an MMAC site visit.
MMAC will attempt to accommodate all requests from other state Medicaid programs needing a pre-enrollment or post-enrollment site visit to be conducted in Missouri. If you are a provider who is attempting to enroll in another state’s Medicaid program and are advised you will need a site visit, please ask that state to contact the MMAC Provider Enrollment Manager at MMAC.ProviderEnrollment@dss.mo.gov. If you are an out of state provider attempting to enroll with Medicaid in Missouri and require a pre-enrollment site visit before you can be enrolled, MMAC will request that the Provider Enrollment unit in your state conduct the site visit on MMAC’s behalf.
Please contact MMAC.Provider.Enrollment@dss.mo.gov with any questions.
Current state and federal regulations (13 CSR 65-2 and 42 CFR 455.410) require ordering, prescribing or referring (OPR) providers to enroll with Medicaid, even if they do not accept Medicaid. In response, MO HealthNet has begun implementing changes in the claims processing system to deny all claims that require an order, prescription or referral from a physician or other licensed health care professional unless that physician or provider has an active enrollment record on file.
The Mo Healthnet Remittance Advices for Pharmacy, Durable Medical Equipment (DME), Independent Laboratory medical claims, Imaging medical claims, and Home Health claims contain the following alert when the ordering, prescribing, or referring provider on the claim is not an actively enrolled provider:
N613 Alert: Although this was paid, you have billed with an ordering provider that needs to update their enrollment record. Please verify that the ordering provider information you submitted on the claim is accurate and if it is, contact the ordering provider instructing them to update their enrollment record. Unless corrected, a claim with this ordering provider will not be paid in the future.
In the future, the alert will appear on all institutional claims. Afterward, the claims processing system will begin to deny the affected claims. In order to ensure that future claims are not denied, the ordering, prescribing, or referring providers must be enrolled with MO HealthNet. In order to ease this process, the Missouri Medicaid Audit and Compliance Unit (MMAC) provides an
Ordering, Prescribing, and Referring (OPR) Provider Application. MMAC’s provider enrollment personnel will expedite all OPR applications received.
If you have any questions please contact MMAC.ProviderEnrollment@dss.mo.gov
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. For shipped or delivered prescriptions, the pharmacy must obtain the signature of the participant or his/her representative and their relationship to the participant. 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.
In February, 2016, the Missouri Medicaid Audit and Compliance Unit (MMAC) posted a prescription fraud alert on its website. Click here to view the full post.
Some of these fraudulent prescriptions are still being presented to Missouri pharmacies. If your pharmacy is presented with a fraudulent prescription, please call your local law enforcement agency. If the fraudulent transaction involves a Medicaid participant, please continue to contact MMAC in addition to your local law enforcement agency.
Contact MMAC at MMAC.Lockin@dss.mo.us with any questions or concerns.
State and federal regulations (13 CSR 65-2 and 42 CFR 455.460) require Missouri Medicaid Audit and Compliance (MMAC) to collect an application fee from all new and revalidating “institutional” Medicaid providers. “Individual” providers such as physicians, dentists and other individual non-physician practitioners are not required to pay the application fee.
The application fee is currently set at $554.00, and it will increase to $560.00 on January 1, 2017.
Click here to read more about the application fee and hardship waivers.
Extended Women’s Health Services cover family planning-related services, pregnancy testing, sexually transmitted disease testing and treatment, including pap tests and pelvic exams, and follow-up services. They are covered by MO HealthNet for uninsured women who are 18-55 years of age with a Modified Adjusted Gross Income for the household size that does not exceed 201% of the Federal Poverty Level (FPL). The Medicaid Eligibility (ME) Code is “80/89”.
House Bill No. 2011, 2016 Regular Session, is the appropriations bill for the Missouri Department of Social Services for State Fiscal Year 2017. Section 11.550 of HB2011 is specific to Extended Women’s Health Services, and prohibits the disbursement of any funds, directly or indirectly, to subsidize abortion services or procedures or administrative functions, and also prohibits the use of any funds to pay an organization that provides abortion services. Qualified organizations, however, shall not be disqualified from receiving funds because of an affiliation with an organization that provides abortion services as long as the two organizations are independent of one another. The bill states that the independent affiliate providing the abortion services must be separately incorporated from any organization receiving these funds.
Missouri Medicaid Audit and Compliance (MMAC) is notifying all providers that may potentially be affected by this restriction. Providers will be notified via e-mail addresses that are on file with MMAC as well as by US Mail.
Organizations that are equipped to provide abortion services will be provided with an attestation that allows them to indicate they do not provide abortion services, if they do not. The organization will attest on behalf of any affiliated providers who submit 80/89 claims, if applicable. The attestation may be returned to DSS in order to ensure no interruption in claims processing for 80/89 claims. Affiliated organizations will also receive an informational letter so they are aware of the restriction and its potential impact on their reimbursement for 80/89 claims. This change does not affect any other Medicaid funding.
Please contact MMAC at MMAC.ProviderEnrollment@dss.mo.gov
