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Partnering with New Mexico for Medicaid Recovery Audit Services New Mexico Provider Associations and Providers in Upcoming Audits September 19, 2013
Partnering with New Mexico for
Medicaid Recovery Audit Services
New Mexico Provider Associations and Providers in
Upcoming Audits
September 19, 2013
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Agenda
» HMS Overview
» What is Medicaid RAC
» New Mexico RAC Overview
» Provider Service & Protocols
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Our Mission & Vision
»» HMS’s Mission We work passionately to increase
the value of the healthcare system for payors and
sponsors. Our solutions drive payment and clinical
accuracy and quality so that healthcare dollars can
benefit more people.
» HMS’s Vision To power the healthcare system with
integrity.
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HMS Holdings Credentials
» Serving government healthcare programs since 1985
» 45 Medicaid Program integrity contracts, including over 30 Medicaid RACs
» In 2012, HMS recovered over $3.2B on behalf of our clients
» Medicare Program Integrity, Midwest Program Safeguard Contractor
» Medicare RAC
HMS is a strategic source for innovative cost containment solutions for
healthcare industry clients
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01. WHAT IS MEDICAID RAC
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HMS’s Medicaid RAC Standards
Reduce provider abrasion, customer service, and limit administrative costs
Possess in depth knowledge of NM Medicaid policies, regulations and MMIS processes
Maintain an understanding of the state’s operating environment – political, provider associations, agency goals
Experienced in coordinating with other state audit entities
Have established processes for 1) receiving and formatting Medicaid data and 2) proven provider relations
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Overview of Review Process
Analysis
And Targeting
Review/Audit
• Program Analysis
• Data Mining/Scenario Design
• State Approval
Record Request
• Provider Contact
• Record Request/Receipt
• Tracking/follow up
• RN/Certified Coder Review
• Physician Referral
• QA and Client Review/Approval
Notification
and Recovery
• Notification Letter
• Provider Reconsideration/Appeal
• Recovery Support
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Meeting and Exceeding RAC Final Rules
Credentials
• Certified Coders
• Registered Nurse Reviewers
• Panel of Licensed Physicians
Customer Service
•Dedicated Toll-free Number
•NM Trained Customer Services Representatives
•Web-Based Provider Portal
Coordination
•With Federal or Other State Agencies
•With Previous SURS/TPL Review Efforts
•With Medicare RAC, Medicaid Fraud Control Unit (MFCU), etc.
Transparency
•Perform Provider Address Checks
•Detailed Recovery Letters
02. NEW MEXICO RAC OVERVIEW
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Types of Reviews
1) Automated Review is applied in scenarios where
improper payments can be identified based on data
analysis alone
2) Complex Review is required when data analysis
identifies a potential improper payment that requires
record review for validation
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NM RAC Specifics
» Three Year Look Back Period from Original Paid Date
» No State (NM) Limit Set on Records Request
» Record Submission Options:
• Secure Web submission
• Fax (877) 829-9080
» Provider Resources
• Questions Call Provider Services - (855) 534-2237
• Web portal - Status on Claims
• Website:
•HMS-NM RAC P.O. Box 168327
•Irving, TX
•75016-8327
•HMS-NM RAC P.O. Box 168327
•Irving, TX
•75016-8327
HMS-NM RAC P.O.
Box 168327 Irving,
TX 75016-8327
Timing is Everything!
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Automated
30 Days to respond to Preliminary Findings of Fact
Agree send check
Disagree, respond in 30 days to HMS
Continued disagreement 30 days to submit to HMS to forward to HSD for Provider Hearing
Complex
30 Days to submit medical records (electronic, mail or fax)
60 Days for HMS to review
30 Days to respond to Preliminary findings of fact
Agree send check
Disagree, respond to HMS in 30 days
Continued disagreement 30 days to submit to HMS to forward to HSD for Provider Hearing
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Technical Denials
Day 1 • Request sent to provider following initial mailing
Day 10 • Follow-up call made to provider following initial mailing
Day 30 • Technical Finding (denial) letter sent to provider 30 days
from the initial mailing if the provider fails to respond
Day 45 • Request for Recovery sent to Provider, if the Provider
Fails to Respond
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Appeal Information
» Level #1:If you are in disagreement, send your response and additional
documentation to HMS, you will receive a response either upholding or
denying
» Level #2:If you have received a denial and are in disagreement, send a copy
of your denial, your response and additional information to HMS. This will
be forwarded to HSD for the Provider Hearing process
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Recovery Method
Make checks payable to:
New Mexico Human Services Department HSD
P.O. Box 25784
Albuquerque, New Mexico 87125-5784
» By Check Only
» No Provider Recoupments
» Send Check to the following address:
NM Provider
P.O. Box 12345
Albuquerque, New Mexico 11111-1111
03. PROVIDER SERVICES & PORTAL
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Provider Portal
» HMS NM Provider web site: http://www.hsd.state.nm.us/mad/
About HMS
NM RAC Provider Information
& HMS Contact Information
» The Provider Portal:
Secure website that allows providers the ability to manage their RAC reviews
More than 15,000 providers currently use HMS’s Provider Portal
Contact information can be updated by providers
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Live Demo
» Provider Portal
• What it’s used for
• Functionality
• How to Check Claims Status
• Documentation submission
» How to sign up &
User guide https://ecenter.hmsy.com
Contact Information
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HMS Account Team:
Cristhian Bermudez, Arizona Program Director Phone: (602) 954-8380 x 108 email: [email protected] Anna Annon Arizona Program Manager Phone: (505) 470-5593 x 107 email: [email protected] HMS Provider Services Team p: (855) 534-2237 f: (877) 829-9080
