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Common Medicaid

Billing Pitfalls

NJAMHAA Annual Conference

March 2017

Your Presenters

Sherise D. Ritter, CPA, CGFM, CGMAManaging Director; Co-chair, Nonprofit & Human Services Groupsritter@mercadien.com; 609-689-2325

Kyle A. Neeld, CPA, CGMAManaging Director; Co-chair, Nonprofit & Human Services Groupkneeld@mercadien.com; 609-689-2360

Pazit KaplanSupervising Senior Accountant; Compliance Oversight Services Grouppkaplan@mercadien.com; 609-689-2416

Agenda

• Fee For Service (FFS) Medicaid Billing Environment

• Eligibility Requirements

• Allowable (Billable) Activities And Billing

• Consumer Case Study

• Best Practices and Controls

• Medicaid Management Information System Overview

• NJ Medicaid Fraud Division Overview

• Medicaid Billing Issues – Common Findings

Medicaid and Fee-For-Service

• Provider agencies must bill Medicaid if consumer is Medicaid eligible

• Consumers not covered by Medicaid will be paid through NJ Mental Health Application for Payment Processing (NJMHAPP)

• Effective Date(s) January 1, 2017 (Phase I) July 1, 2017 (Phase II)

Medicaid Program

• Medicaid considered higher risk program by Dept. of Health & Human Services.

• Focus on improper payments - should not have been made or incorrect amounts (including overpayments, underpayments, duplicate payments) under statutory, contractual, administrative, or other legally applicable requirements.

State Medicaid Fraud Control Units (MFCU)

Investigate and prosecute fraud by Medicaid providers.

Review complaints alleging abuse or neglect of patients or consumers.

Review complaints of misappropriation of patients’ private funds in such facilities.

Eligibility Requirements

Eligibility

• In order to bill for services provided, consumer must be: In need of medical services Income eligible (Medicaid)

• Provider agency must: Have contract with NJDMHAS Be NJ Family Care (Medicaid)

provider

Eligibility (cont.)

• Process to review changes in eligibility (agency and consumers)

• Process to ensure consumer eligibility ongoing

Allowable Billable Activities

Allowable Activities

Home and Community-Based Services – A state may obtain a waiver of statutory requirements to provide an array of home and community-based services that may permit an individual to avoid institutionalization (42 CFR part 441, subpart G).

The HHS OIG has issued a special fraud alert concerning home health care, noting cost report frauds, billing for excessive services or services not rendered, and use of unlicensed staff.

The full alert was published in the Federal Register on August 10, 1995, (page 40847) and is available from the HHS OIG home page, Special Fraud Alerts section: http://oig.hhs.gov/fraud/fraudalerts.asp.

Community Care Waiver (CCW)

• Services billed under various codes at different rates based on service, tier and acuity

• Major categories of allowable activities: Day Habilitation Individual Supports (Personal Assistance Services or Training)

Supported Employment Support Coordination Numerous others activities

• Conducted in various settings (group, individual, etc.)

• Records – attendance, progress notes

CCW Rate Sheet

CCW Rate Sheet

Partial Care

• Services billed under one code @ $17.92/hour

• 11 categories of allowable activities, including: Engagement strategies

Goal-oriented activities

Illness management

Coping skills

Medication management

Partial Care Activities Specifics

• Minimum of two and maximum of five 1-hour classes per day per consumer (programming time)

• Up to 15 consumers allowed per instructor for each class

• Various settings – Group

• Records – attendance, progress notes

Adult Mental Health Rehabilitation (AMHR)

• Residential setting

• Rates typically billed on daily basis

• Group and Individual setting

• Records – attendance, progress notes

Billing Units

• CCW – billing unit based (hour - minutes aggregated) (15 minutes - consecutive minutes) or daily (current waiver does not specify consecutive minutes)

• Partial Care – based on programming time (units of service for a day)

• AMHR –billing unit based (consecutive minutes)

Billing Environment Considerations

• Assign consumers to specific billing codes based on their plan

• Templated documentation based on coding

• Progress notes – must be detailed

• Need review process – code management, ensure progress notes are complete and detailed and accurate attendance records exist

Consumer Case Study

CCW Consumer Profile

• Consumer A • Lives in a Group Home • Receives individual supports services• Receives day habilitation services

CCW Consumer Example

Service/Tier HoursUnits per consumer Projected Revenue

Day HabilitationTier B 25 100 2.99$ /15 min 299.00$

Individual Supports - Group Home, Supervised ApartmentTier B n/a 7 141.04$ /Day 987.28$

1,286.28$

Monthly Estimate 5,573.88$

Community Care Waiver

Rate

Partial Care Consumer Profile

• Consumer B • Attends 5 (1) one hour classes per day, 5

days per week

Partial Care Consumer Example

UnitNumber of Classes per

Week Projected Revenue

Class 25 17.92$ /Hour 448.00$

Number of consumers per class average 10

Weekly revenue average 4,480

Monthly Estimate 19,413.33$

Partial Care

Rate

Billing Records

• Progress Notes – must describe the services provided and should be as detailed as possible to support the services rendered and billing done (coding)

• Daily Training Records – document consumer progress towards goals and objectives, needs to be signed by employee each time a goal/objective is worked on

• Attendance Records – record of attendance to support and supplement the progress notes and daily training records.

Sample Progress Note

Progress Note Requirements

• Specific

• Who, what, when, how

• Signed (required licensed?)

• Dated

• Timely

• Legible

Sample Progress Note

Daily Training Record Example

Daily Training Records

• Specific• Who, what, when, how• Signed (required licensed?)• Dated• Timely• Legible• Contains details about action provided to meet

consumer plan objectives

Daily Training Record Example

• Sally will shower daily with physical assistance with 60% accuracy for one year.

• Sally will assemble a puzzle one time per month independently with 80% accuracy for one year.

• Sally will brush teeth twice per day for 2 minutes with 90% accuracy for one year.

Attendance Record Example

Best Practices and Controls

Best Practices

• Establish a system of internal controls over Medicaid compliance

• Provider agencies must abide by state plan and waivers under the federal compliance rules

• Consider internal audit and compliance departments

• Designate education and training compliance officer

• Written policies and procedures

Best Practices (cont’d)

• Ensure the EHR systems are set up properly

• Appropriate employee screening at onboarding & annually

• Discipline and incentives

• Training on what can go wrong

• Investigation and corrective action

Billing Controls

• Ensure consumer’s eligibility is current (process)

• Ensure services were provided and documented

• Ensure consumer information correct

• Quality control process to review billing prior to submission

• Monitor minimum service efforts (process)

• Process to review progress notes and attendance records

• Process to review status of claims billed

• Process to adjudicate any denied claims

• Liaison to act as intermediately between billing and clinical to educate clinical staff about billing and denials

Training Program

• Ensure employees know how to code• Ensure employees know how to document• Ensure employees know what to look out for

Example: Billing department has to interface with Program Directors at some level i.e. continuing to bill during absences or

vacancies

Medicaid Management Information System

Medicaid Management Information System (MMIS)

• A required mechanized benefit claims processing and information retrieval system. HHS provides general systems guidelines. Systems vary by state and may be maintained and operated by the state or a contractor.

• NJ MMIS is currently Molina Information Systems (April 2010).

• Normally used to process payments for most medical and waivered services.

• Supports Claims Receipt and Adjudication and Point-of-Service subsystems to process provider claims.

• Clinicians need to know what drives the billing.

NJ Medicaid Fraud Division

NJ Medicaid Fraud Division

• Under the Office of State Comptroller, works to improve efficiency and integrity of NJ Medicaid, FamilyCare and Charity Care programs by investigating, detecting and preventing Medicaid fraud and abuse. Serves as watchdog over providers and recipients of services in order to ensure that services are delivered in a quality manner to those who truly qualify for them.

• 3 Units:

Fiscal Integrity Investigations Regulatory

Medicaid Fraud Division- Audit Unit

• Audits Medicaid providers to ensure compliance with program requirements and identify overpayments.

• Coordinates, oversees and reviews the audit work of other state agencies or third-party contractors (if MAC audits ever take place).

Risk Factors for Auditee Selection

• $ billed annually• Provider type• Significant change in billings on a year to year basis• Complaints from the public• Providers subject to corrective action plans• CMS or OIG alerts regarding fraud and abuse taking

place in other states• Prior audit history• Services billed vulnerable to fraud, abuse or waste

Scope of Typical Medicaid Audit

• Audit unit sends letter alerting provider that it will be audited -scope, date of entrance conference

• Field audit for compliance• Exit conference• Issues draft audit report w/ proposed recovery and basis for

internal control weaknesses and recommendations• 10 days for provider to respond (business days)• No response = final report• Objections to draft report allowed • Fraud uncovered - audit team refers findings to the MFD

Investigation Unit

Medicaid Billing Issues –Common Findings

• Service plan not present, approved, completed timely or meet requirements of a Qualified Intellectual Development Professional.

• Self care assessment tool (SCAT) not present, approved, completed timely or meet requirements of a Qualified Intellectual Development Professional.

• Level of care (LOC) assessment not present, approved, completed timely or meet requirements of a Qualified Intellectual Development Professional.

• Agency had no record of consumer being present for date of service recorded in the Medicaid Management Information System.

• Agency could not provide consumer file or attendance sheet and daily training record to support the units of service.

Common Findings from Medicaid Compliance Reviews

• No daily training record, skill tracking sheet or progress note to support units of service or identify staff providing service.

• Nursing assessment not available or completed on a timely basis.

• Nursing assessment did not include recommendation for appropriate level of care.

• Comprehensive service plan not available, completed timely, did not include current level of care, not signed by RN or higher level professional.

• 90-day nursing assessment not available, completed timely, signed or did not indicate that observations and progress notes were reviewed.

Common Findings from Medicaid Compliance Reviews (cont’d)

• Progress notes did not contain signature, title, date or time of entry.

• Supported employment staff members did not receive required training, training not received timely or supporting documentation not present.

• No employee file present or employee files did not contain evidence that employee received high school diploma or equivalent.

• Employee file did not contain signed job application, reference checks, medical clearance, or criminal background checks.

Common Findings from Medicaid Compliance Reviews (cont’d)

• Provider agency continued to bill after consumer discharged (aggregate amount >$50,000).

• Terminated employee took 6 months of consumer files that contained progress notes, consumer service plan and other consumer documents (HIPAA violation).

Common Findings from Medicaid Compliance Reviews (cont’d)

Questions?