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• PERM Program Overview
• Claims Data Submission
• FFS and Managed Care Sampling
• FFS Details Data
• State Policy Collection
• Data Processing Reviews
• Medical Records Requests
• Medical Reviews
• Tracking Errors and Responding to Findings
• Improper Payment Rate Reporting
• Next Steps
• PERM Eligibility Component
• Communication and Collaboration
• Available Resources
• Contact Information
Learning Objectives
2
PERM Program Overview
• CMS is required to estimate the amount of improper payments in Medicaid and CHIP annually by the IPIA (now amended by IPERA and IPERIA)
• The goal of PERM is to measure and report an unbiased estimate of the true improper payment rate for Medicaid and CHIP
• Because it is not feasible to verify the accuracy of every Medicaid and CHIP payment, CMS samples a small subset of payments for review and extrapolates the results to the “universe” of payments
• The program is currently operating under the PERM final regulation published in August of 2010
• This cycle will review Medicaid and CHIP payments made in Fiscal Year (FY) 2017 (October 1, 2016 through September 30, 2017)
• The FY 2017 improper payment rates will be reported in November of 2018
3
Claims Data Submission
• States must submit valid, complete, and accurate claims universes to the SC
• States have 2 data submission options – must choose by September 15, 2016– Routine PERM
– PERM+ For more information on the submission options, contact
Please note that T-MSIS will not be used for FY17 PERM data submission, although its use is currently being evaluated for the future and CMS will continue to update states on its progress
• An intake meeting is held with each state to discuss– Requirements of PERM claims data submission
– Medicaid and CHIP programs and payment structures
– All data sources and the data collection process for PERM
– Waivers, demonstrations, and other programs in the state
– Any state-specific considerations around staffing structure and processes
5
Claims Data Submission
**New** Additional Intake Meeting
• Separate Data Intake Meetings will focus on required data fields to be included in state submissions, formatting options, file layouts (planned to take place in November)
– States will be required to submit file layouts mapping their data variables in state system(s) to variables requested for PERM prior to the data intake meeting
– The SC will review PERM requirements with the state data team
– In depth review of state file layouts - variable by variable - to confirm correct data is mapped to required and proper fields
– Note challenges/missing information from the state
– Walk through any potential data merging issues with PERM+ states
– Discuss header vs line data submission and payment levels
– Address any PHI/PII concerns
– Introduce PERM SFTP access, setting up credentials, security protocols
6
**New** Additional Intake Meeting
• CMS 64/21 Intake Meetings will include the PERM contacts and the state’s
financial staff (planned to take place in October or early November)
– Introduce the CMS 64/21 comparison and reconciliation process, as
part of the PERM program
– Discuss the expected timeline for completion of this process
– Walk through a sample of the financial summary documents that will
be prepared for each state program
– Review the state’s comparison and reconciliation process from the
previous PERM cycle
– Answer any questions that the state staff may have regarding this
process
Claims Data Submission
7
Claims Data Submission
• Claims data due dates
• The SC will work with the state to ensure all PERM submission requirements are met each quarter
– Timely communication and efforts early on in the cycle will help the process for subsequent quarters and phases of PERM
– The SC performs a series of quality control checks
– The SC also performs a comparison of PERM data submission to CMS-64/21 reports
Quarter Paid Date Due Date
Quarter 1 October 1 – December 31, 2016 January 15, 2017
Quarter 2 January 1 – March 31, 2017 April 15, 2017
Quarter 3 April 1 – June 30, 2017 July 15, 2017
Quarter 4 July 1 – September 30, 2017 October 15, 2017
8
FFS and Managed Care Sampling
• **New** Return to payment stratification for FFS sampling
– In FY 2014, the SC separated claims from four preselected service
types into eight service based strata; the rest of the claims were
separated into three payment-based strata, with the addition of one
zero/denied paid claim stratum
– In FY 2017, the SC will select samples from ten payment strata (with
the addition of a fixed payment stratum) and one zero/denied paid
claim stratum
• State-specific Medicaid and CHIP sample sizes based on FY
2014 results
– Each state will receive its sample size notification on August 31, 2016
9
FFS Details Data
• Details data is used to request medical records and conduct medical review for sampled FFS claims
– Submitted by routine PERM states
– SC creates details file for PERM+ states
• As in FY 2014, the SC will hold details intake meetings with routine PERM states to:
– Provide an overview of the details data requirements
– Discuss details intake protocol
• **New** Details intake meeting held with PERM+ states to:
– Review details built by the SC
– Verify information to support medical record request
• The SC performs a series of quality control checks and sends questions on any missing/incomplete/invalid information to the states
• The SC may require regular meetings to resolve data issues if there are significant complications or delays 10
State Policy Collection
• The RC will collect state Medicaid and CHIP policies in order to conduct reviews
• Policies may include rules/regulations, manuals, handbooks, bulletins, updates, notices, clarifications, reminders, fee schedules, codes, etc.
• The RC will download all publically available state policy documents relevant to the medical review of claims and create a master policy list for each state
• The RC submits policy documentation to each state for review and approval– Medical Review/Policy Questionnaire
– Master policy list
• The RC continues policy collection throughout the measurement and validates with the state as appropriate
• All policies for medical review and desk aides for data processing review will be available to states and reviewers in SMERF to access policies used when an error is cited
11
Data Processing Reviews
• RC educational webinars are held with all states in the cycle to review the Data Processing (DP) Review process before starting DP Reviews **New** The RC will also have individual check-in calls with
each state throughout the cycle, as needed
• DP reviews are conducted on each sampled FFS claim, fixed payment, and managed care payment
• The RC validates that the claim was processed correctly based on information found in the state’s claims processing system and provider files
• Reviews can take place on-site at the state or remotely **New** Average on-site review time will increase from 2-4
weeks to 3-8 weeks due to increased sample sizes and review requirements (including ICD-10, FCBC, revalidation, etc.)
12
• Data Processing orientation is scheduled with each
state prior to reviews to:
– Review state system(s) questionnaires completed by states
– Review any special programs (waivers, etc.)
– Demonstration of any new systems
– Determine and gather desk aids, manuals, and website links
needed for training DP reviewers
– Discuss remote vs. on-site reviews and establish tentative
dates to begin reviews
– **New** States complete DP checklist in preparation for
DP Reviews
Data Processing Reviews
13
• **New** States track pending DP reviews real time
through SMERF and receive automated notices for
overdue pending information needed to complete
reviews
**New** Claims on the P1 list will be converted to errors
after the 31st day of pending with no response from the
state, but documentation can still be submitted until the end
of the cycle, similar to the process for MR1 and MR2
errors
**New** All pending documentation now submitted to RC
centralized office in Rockville, MD
Data Processing Reviews
14
Data Processing Reviews
Recipient ID
Date of Death
Date of Birth/Age
County of Residence
Gender
Citizenship Status
Living Arrangements
Aid category and benefit
plan
Managed Care Enrollment
Rules and History
Patient Liability (share of
costs), if applicable
Medicare and/or other
insurance coverage (TPL)
Eligibility Source System
Verification
DP Review Elements - Recipient
15
Data Processing Reviews
Name
NPI Number
Active Enrollment
Active License (if required)
Active CLIA (if required)
Type/specialty
Service Location
Sanctions
Suspension Periods
OIG Exclusion List
Risk-based screening of newly enrolled
providers
**New** Provider revalidation – claims
paid after 3/24/16 (unless provider was
notified prior to 3/24/16; then must be
screened by 9/24/16)
**New** Fingerprinting and criminal
background checks for high risk
providers for claims paid after 6/1/2016
or the date of a CMS approved
compliance plan
Verification of Provider Enrollment(only applicable when provider is required to be enrolled)
16
Data Processing Reviews
Verification of Accurate Payment• Determine whether the claim was filed timely
• Determine compliance with HIPAA 5010 transaction standards
for electronic claims
• **New** Determine if system uses ICD10 codes for claims
with DOS on or after 10/1/2015
• Was the claim for a covered service?
• Was the claim priced accurately based on the Fee Schedule in
effect for the date of service?
• Determine if the claim is a duplicate of a previously paid claim
• Identify, report, and consider any adjustments to the sampled
payment made within 60 days of original payment
17
Data Processing Reviews
Miscellaneous Payment Information
Prior Authorizations (PA) required under the state’s policies
View and compare scanned images of hard copy claims and
attachments with system information
Payments for “Sister Agencies” that receive pass-through
Federal Financial Participation (FFP)
18
Data Processing Reviews
Managed Care Capitation Payment
Recipient information
Health Plan information
Capitation Rates per
Health Plan
Geographic Service areas
(county, zip code, etc.)
Rate Cells
Exclusions/Carve Outs
Capitation Payment history
screens
Partial month
coverage/recoupment policy
Roll-Out dates (if staged
implementation was in
effect)
Duplicate
payment/adjustment check
19
Data Processing Reviews
20
Error Code Name
DP 1 Duplicate Claim
DP 2 Non-Covered Service/Recipient
DP 3 FFS Payment for a Managed Care Service
DP 4 Third-Party Liability Error
DP 5 Pricing Error
DP 6 System Logic Edit Error
DP 7 Data Entry Error
DP 8 Managed Care Rate Cell Error **New Name**
DP 9 Paid Incorrect Managed Care Rate **New Name**
DP 10 Provider Information/Enrollment Error **New**
DP 11 Claim Filed Untimely **New**
DP 12 Administrative/Other Error
DTD Data Processing Technical Deficiency
Initial FY 2017 PERM Data Processing Error Codes
**New** Expanded qualifiers to more specifically identify reasons for error
Medical Records Requests
• The RC makes initial calls to providers to verify provider information upon
receipt of details files from the SC and notifies state PERM representatives prior
to starting calls to providers
• The RC establishes a point of contact with providers and sends record requests
Providers have 75 days to submit documentation
• The RC makes reminder calls and sends reminder letters on day 30, 45, and 60
until the record is received
If the provider does not respond, the RC sends a non-response letter on day
75 (copied to states in weekly batches)
• If submitted documentation is incomplete, the RC requests additional
documentation The provider has 14 days to submit additional documentation
A reminder call is made and a letter is sent on day 7
If the provider does not respond, the RC sends a non-response letter after 14 days
(copied to states in weekly batches) 21
Medical Records Requests
• **New** Two new letters are sent to providers, when needed Receipt of Incomplete Information letter
Resubmission letter
• **New** All medical record request letters have been made standard to match
all other CMS request letters sent to providers
• **New** The RC will establish an SFTP account for each state in order to
facilitate submission of PHI and make record submission easier overall
• **New** All letters sent to providers are copied to the RC’s SFTP site and made
available for each state
• The RC will accept and review late documentation (submitted past the 75 day
and 14 day timeframe) until the cycle cut-off date (July 15, 2018)
• State involvement is essential in obtaining necessary documentation from
providers
• The RC will attend a series of interactive PERM Provider Education Webinars
hosted by CMS for provider outreach22
Medical Reviews
• Medical Review orientations are held for all cycle states, as part of the RC
Educational Webinars, to include
Medical Review process
Difference Resolution/Appeals process
Medical Review/policy questionnaire
• Conducted only on sampled FFS claims
• Utilizes claims data submitted by states, records submitted by providers, and
collected state policies
• Validates whether the claim was paid correctly by assessing the following
Adherence to states’ guidelines and policies related to the service type
Completeness of medical record documentation to substantiate the claim
Medical necessity of the service provided
Validation that the service was provided as ordered and billed
Claim was correctly coded
23
Medical Reviews
24
Error Code Name
MR 1 No Documentation
MR 2 Incomplete Documentation **New**
MR 3 Procedure Coding Error
MR 4 Diagnosis Coding Error
MR 5 Unbundling
MR 6 Number of Unit(s) Error
MR 7 Medically Unnecessary Service
MR 8 Policy Violation
MR 9 Inadequate Documentation **New**
MR10 Administrative/Other
MTD Medical Technical Deficiency
Initial FY 2017 PERM Medical Review Error Codes
**New** Expanded qualifiers to more specifically identify reasons for error
Tracking Errors and Responding to Findings
• **New** An RC cycle manager has been added to facilitate state
implementation, confirm readiness prior to on-sites or remote
reviews, provide IT support, and overall reduce state burden
• State Medicaid Error Rate Findings (SMERF) system Track medical records requests
Track medical and data processing reviews
Access SUD, Y-T-D Errors, and Recoveries reports
Request difference resolution and appeals
Access improper payment rates and final findings
• SMERF system orientations are held for all states before records are
requested or Data Processing and Medical Reviews are started
25
• **New** The RC has enhanced SMERF 2.0 to be more user-
friendly and have increased functionality
Claims Detail Screen: Enhanced view of providers by type on the provider tab;
realigned Medical Records information on claim look-up in descending order,
with the most recent communication listed at the top of the page
Policy Menu: Policies collected and displayed were enhanced to include
access to DP desk aids and Federal Regulation citations used by reviewers and
states
Reports Menu: Expanded to include DP Pending (P1) reports that are updated
real time to communicate with states on information needed to complete
reviews; PERM alerts will be sent from SMERF to advise states when pended
reviews are past the 14 day response time
Recoveries Menu: Added Final Recovery Status reports that display all
overpayment errors reported on the FEFR report and information on the status
of recoveries
Tracking Errors and Responding to Findings
26
• **New** The RC has enhanced SMERF 2.0 to be more user-
friendly and have increased functionality
CAP analysis tab: Provides first level access to MR Error Analysis and DP
Error Analysis; enables users to filter and group MR errors by search results
by Year, Program, Claim Category, Error Code and Qualifiers; for DP errors by
search results by Year, Program, Component, Error Code and Qualifier
Individualized reports: States can select from data elements available which
data are needed for their reports by selecting needed fields in the drop down
menu; standard reports can still be provided as default, if needed
CAP Addendum report (To be added to SMERF 11/2016): States will be able
to track any final error changes made during continued processing and use the
information in developing their CAP response
CAP Interactive Module (To be added to SMERF 9/2017): In the future, states
will be able to develop their CAPs, make revisions, and receive
acknowledgment and approvals from CMS through SMERF; notices will be
sent by the system for each action taken in this module
Tracking Errors and Responding to Findings
27
Tracking Errors and Responding to Findings
• States receive advanced notice of every DP and MR error identified **New** All DP and MR errors will be cited, increasing the opportunity for
states to identify and correct any issues
• Errors are officially reported to states through Sampling Unit
Disposition (SUD) reports on the 15th and 30th of each month
• The state has 20 business days from the SUD report date to request
a Difference Resolution (DR) States must request difference resolution to re-price partial errors
• States have 10 business days from DR decision to appeal errors to
CMS
• States are required to return the federal share of overpayments
identified on sampled FFS and managed care payments
• States are required to develop a Corrective Action Plan (CAP) to
address each error28
• The official Medicaid and CHIP national rolling
improper rates are reported annually in the Agency
Financial Report (AFR) each November
• Following the posting of the AFR, each state receives
its state-specific improper payment rates and findings
through the Error Rate Notifications, Cycle Summary
Reports, and CAP Templates
• This release of official improper payment rates marks
the beginning of the corrective action process
Improper Payment Rate Reporting
29
Next Steps
• August 2016• Complete universe data submission survey by August 15
• FFS and managed care sample sizes verified by August 31st
• September 2016 Communicate decision between PERM+ and routine PERM by September 15
Data submission instructions distributed to states
PERM General Education Webinars
Claims orientations/intake sessions begin
• October – December 2016 Alert Lewin no later than October 1 if DUA is needed for data submission
Claims orientation/intake sessions continue
Prepare for universe data submission
• January 2017 Q1 claims data due January 15
30
• The FY 2017 cycle will not consist of an eligibility component
• State-specific improper payment rates will be calculated based on the FFS and managed care
components– No state-specific PERM eligibility improper payment rates will be calculated
• At the national level, CMS will report comprehensive Medicaid and CHIP improper payment rates
based on the continuing FFS and managed care reviews and a proxy eligibility component improper
payment rate
• Medicaid and CHIP Eligibility Review Pilots have replaced the PERM eligibility component and
MEQC traditional pilots for FY 2014 – FY 2017– All states are required to conduct 5 Medicaid and CHIP eligibility review pilots over the 4 year period
– As stated in the State Health Official (SHO) letter # 15-004, dated October 7, 2015, a Federal ERC will
conduct the Round 5 eligibility reviews for the Cycle 3 states
– The Round 5 eligibility pilots are intended to be a “dry run” of future PERM eligibility reviews
• The ERC will utilize the Cycle 3 states’ quarter 1 FY 2017 PERM cycle FFS/managed care claims
sample to identify cases for eligibility reviews during the Round 5 eligibility pilots
• The ERC will conduct reviews according to guidelines outlined in Standard Operating Procedures
(SOP) drafted and refined during three rounds of the Eligibility Support Contractor (ESC) pilot
studies where Federal contractors conducted state eligibility reviews. Under the SOP, eligibility
reviews are broken in four phases: planning, kick-off, case reviews, and final findings and wrap-up
PERM Eligibility Component and
the Eligibility Review Contractor (ERC)
31
Round 5 Pilots Eligibility Review Phases
32
Phase Description
Planning During the planning phase, the ERC will complete all required agreements with each
state; conduct eligibility review educational webinars; gather state-specific
Medicaid/CHIP eligibility policies, systems, and review process information; and
request and receive system access from each state
Kick-Off In phase two, the ERC will work with the state to collect more detailed information
about the state’s eligibility processes and policies
Case Reviews In phase three, the ERC will be conducting the case reviews and providing findings
to the state; the frequency of findings report submission is weekly or biweekly,
depending on state preference
Final Findings and Wrap-up In the final phase of the pilot, the ERC will present the state with its final findings;
the state is allowed to review the final findings for accuracy and point out any
discrepancies, but it is not allowed to contest any of the final findings, as all case
review findings should have gone through the informal and difference resolution and
appeals process during Phase Three
• The process of using an ERC and the FFS/managed care claims sampling methodology is a
new approach to eligibility reviews for the Cycle 3 states. Thus, it is imperative that Cycle 3
states plan to:
– Collaborate with essential state staff to successfully complete each phase of the pilot and support the
ERC, including Medicaid/CHIP policy staff, eligibility system(s) staff, quality control staff, etc. All
staff should plan to be actively engaged. We recommend that states begin identifying a team of staff
members who will be involved in the pilot as soon as possible and begin coordinating amongst the
various departments in order to prevent delays.
– Be prepared to provide the ERC all information used by the state to make the eligibility determination
that is under review, through direct system access and/or by providing hard copy case file
documentation.
• For more information please visit: http://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicaid-and-CHIP-
Compliance/PERM/FY2014_FY2016EligibilityReviewPilots-.html
– Additionally, CMS will provide more detailed information regarding the Cycle 3 states
responsibilities in Round 5 of the FY 2014-2017 Medicaid and CHIP Eligibility Review Pilots
– CMS will introduce the ERC next month
• Please submit any questions to the mailbox: [email protected]
PERM Eligibility Component:
Collaboration and Next Steps
33
Communication and Collaboration
• FY 2017 PERM Cycle 3 Calls
The cycle calls will occur on the Fourth Tuesday of each
month from 3:00 – 4:00 pm Eastern Time
First cycle call will be held on Tuesday, October 25, 2016
• PERM Technical Advisory Group (TAG)
Quarterly TAG calls as a forum to discuss PERM policy
issues and recommendations to improve the program
Regional TAG reps
• CMS PERM Website
www.cms.gov/PERM
34
Additional Available Resources &
CMS Contact
• PERM Manual
• PERM Standard Operating Procedures (SOP) for state staff
Nick Bonomo, FY 2017 Cycle Manager
410-786-8942
35
The Lewin GroupPERM Statistical Contractor
3130 Fairview Park Drive, Suite 500Falls Church, VA 22042
703-269-5500
All PERM correspondence should be directed to Lewin’s central PERM inbox
SC Contact Information
36
Review Contractor: CNI Advantage, LLC
General Mailbox: [email protected]
Brent Wolfingbarger, Project Director
301-339-6224
Mariam Siddiqui, Regulations/Policy Manager
301-339-6211
Susan Carlson, Corporate Monitor
301-987-2181
RC Contact Information
37
Christina Beckley, Data Processing Review Manager
301-987-1114
Monica Dantzler-Thomas, Medical Review Manager
301-339-6234
Bahar Degirmencioglu, Medical Records Manager
301-987-1107