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OMIG\HMS Integrated Reviews & Provider Portal Cerebral Palsy Associations of New York State April 2011
OMIG\HMS Integrated Reviews & Provider Portal
Cerebral Palsy Associations of New York State
April 2011
Today’s Objectives
• Describe OMIG’s new approach to payment recapture
• Demonstrate how this approach can help optimize recoveries and minimize abrasion
• Provide an overview of the OMIG/HMS Provider Portal
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Where We Are Now
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PI
Provider self-disclosure
Onsite and desk reviews
Credit balance reviews
Data mining
Long-term care review
Institutional reviews
Data matching
Cost avoidance
Third party reviews
Estate and casualty recovery
Direct billing
Disallowances
TPL
Where We Are Headed
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Disallowances
Onsite and desk reviews
INTEGRATIONProvider disclosure
Payment integrity reviewse-Reviews
Fraud referrals
Provider scoring
Institutional reviews
Free standing clinic reviews
Long-term care reviewsDirect billing
Estate and casualty recovery
Data matching
Cost avoidance
Third party reviews
Data mining
ACA Increases Focus on Program
• Section 6402(a) of Affordable Care Act (ACA) requires providers to “report and return” overpayments
• Section 6411(a) requires states to establish contract(s) with one or more Medicaid Recovery Audit Contractors
• Funding to combat fraud, waste and abuse
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NY Medicaid RAC Program
• OMIG has designated HMS as the New York Medicaid RAC with CMS’s approval of the SPA
• Integrated approach shares data across programs
– Maximize identification of payment issues– Reduce future overpayments– Minimize provider burden
• The “integrated approach” will be a central piece to New York OMIG Medicaid RAC Program
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Integrated Approach
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Integrated Approach
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Integrated Approach
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Integrated Approach
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Integrated Approach
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e-Reviews and Data Mining• Uses paid claims data from third party payors and other
external data– Commercial– Medicare– Provider A/R (Credit & Debit Balances)
• Allows for validation of overpayment at time of data mining
• Notifies providers via mail and portal
• Recoveries may be initiated electronically through MMIS
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e-Reviews and Data Mining (cont.)
• More emphasis on provider compliance and program oversight
• Each overpayment is reviewed at the claim level
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• Drives the integration of TPL and PI through data mining
Integrated Approach
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Integrated Approach
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Integrated Approach
16Sentinel Effect = Improved Provider Billing
Question:How are we going to work with the
providers to help consolidate and streamline review distribution, reconciliation and recovery processing?
Answer:OMIG/HMS Provider Portal
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Overview of the Provider Portal
• The Provider Portal is a web-based application that will allow providers a single point of entry for multiple OMIG reviews
• The provider portal is designed to accommodate multiple functionalities
– Third Party Reviews– Payment Integrity Reviews– Provider Self-Disclosures– Medicaid Credit Balance Reporting
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Accessing The Provider Portal
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Web-based with 128-bit security encryption
Login for existing users and requesting a user account
New User Registration
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Select Registration Type to pull up the appropriate registration form
Once the registration form has been submitted the new user will contacted by HMS to verify information
First Time Access
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Enter a new personalized password and confirm
Enter the Current Password given to the provider by HMS during the registration process
Select security questions and answers
Click OK
Home Page
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Select Application/Project
Third Party Reviews
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Once you have selected the appropriate Third Party Review click to open
Each Third Party Review is assigned a “cycle number”.
“Cycle Search” allows the user to search for a specific review.
Third Party Reviews (cont)
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“Recipient Search” function allows the user to pull up all the claims that appeared on Third Party Reviews that belong to a specific patient
Click to view claim detail
Third Party Reviews (cont)
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Click to view claim detail
“Claim Search” function allows the user to pull up a specific claim that appeared on a Third Party Review
Responding to Third Party Reviews (cont)
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Click on the down arrow of “Provider Action/Reasons” to select the appropriate Action/Reasons code
Enter comments regarding the claim in the “Provider Comments” box
Click “Ok” to save the Action/Reasons code and Provider Comments or click “Cancel” to discard changes and exit.
Information identifying cycle number, recipient, and third party coverage
Claim Information
Payment Integrity Reviews• Types of Payment Integrity Reviews
– Automated Reviews (e-Reviews)• Consists of overpayments that can identified with extremely
high accuracy• Provider will be given 30 days to review findings
– Complex Reviews• Potential overpayments where additional information is required
to make a clear determination• Providers required to submit documentation to HMS• HMS reviews the documentation and makes a determination
• Reviews will be sent to providers in a similar fashion as TPR– Target overpayments through data mining– Upload targets to the Portal and notify providers– Providers given clear instructions on how to satisfy each type of
review
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Self-Disclosures
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Upon logging into the provider, users with appropriate will see the Self-Disclosure application listed on their home page.
Click “Select” to access the application.
Self-Disclosures – Input
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Enter recipient’s information
Enter primary payor and payment information (if applicable)
Enter basic claim information needed to identify the claim
Enter refund amount and reason(s) for overpayment
As refunds are entered and saved, they appear at the bottom of the screen
Click “Submit” to submit the report to the “Supervisor” for final review
Self-Disclosures – Search
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Each user is allowed to query for refunds they entered and/or submitted.
Users with “Supervisor” access will be able to query all refund entries for the given provider/facility.
Query options. Enter the search criteria and click “Search”
Search results are returned at the bottom of the page
Click “Export” to export search results to an Excel spreadsheet
Click “Details” to view full information on file
Self-Disclosures – Attestation
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Only the users with “Supervisor” access will be able to formally submit self-disclosures to OMIG-HMS. When submitting the final report, the “Supervisor” will be asked to attest to the information being submitted.
Medicaid Credit Balance Reporting• Batch Reporting
– Will give providers the ability to upload completed worksheets with proper attestation, eliminating claim by claim data entry and reporting
– Supply a report template for providers to use– May require providers who chose to use batch
reporting to under-go acceptance testing to verify correct formatting, accuracy of data, etc.
• Will mirror OMIG initiative to prompt self-disclosures
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What to Watch for in 2011
• Third Party Reviews– Outreach underway to re-register providers to the OMIG-HMS Portal– Anticipate uploading the first Review to the portal around March 21th
• Self-Disclosures– Development completed– Currently in the User Acceptance Testing (UAT) Phase– Looking for initial rollout to a small group of hospitals around April 25th
– Will seek feedback from the early adopters
• Credit Balance Reporting– Currently in the design phase– Anticipating 3 month development and testing
• Payment Integrity Reviews– Currently in the design phase– Anticipating 6 month development and testing
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Timeline
• March 21, 2011 Third Party Reviews
• April 25, 2011 Self-Disclosures
• July 1, 2011 Credit Balance Reporting
• October 1, 2011 Payment Integrity Reviews
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