from admission, and at least once every 60 days thereafter. A physician must certify the need for continued stay. The LTC facility must have physician orders for the resident’s immediate care and must periodically conduct a comprehensive assessment of each resident’s functional capacity (MDS). The MDS must be completed within 14 days of admission. The LTC facility must assess the resident quarterly and an annual assessment must be completed within 366 days after final completion of the most recent comprehensive resident assessment. The LTC facility must develop and implement a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment. Each resident must receive the necessary nursing, medical and psychosocial services to attain and maintain the highest possible mental and physical functional status, as defined by the comprehensive assessment and care plan. The care must be performed by appropriate qualified persons. The LTC facility must ensure the resident does not develop pressure ulcers while in the facility; must reduce the risk of harm resulting from falls; and other patient safety/quality of care concerns. All documentation to support the appropriateness of continued stay must be available for review. In our audits of clinical LTC services, HMS requests and reviews the following documentation from providers (where applicable): Resident Assessment Instrument (MDS) Medicaid Patient Status Notification (Form 199) Form XIX LTC-9 and assessment document PASRR screening information Physician certification(s) Physician progress notes Physician orders Rehabilitative Plan and Treatment Notes (e.g., SP, PT, and OT) Nurses Notes History and Physical Discharge and Transfer Summaries Lab Reports Radiology Reports Interdisciplinary Team Notes Intake and Output Log Vital Sign Log Weight Records Treatment Sheets Therapy Re-evaluations (e.g., SP, PT, and OT) Form 161/Form 161B Form MED-54 Staffing Schedule if quality of care issues HMS incorporates the specialized review techniques described above into our automated, semi-automated, and complex review processes. We describe each of these processes in more detail below. Automated Review Process In our automated review process, an analyst will examine individual claims and various metrics concerning the audit population identified by DMA. Additionally, an internal QA process reviews the population according to the QA criteria
HMS additional documentation into PIE and attaches it to the appropriate case. Our clinical auditors review all additional information and work closely with providers during this process to ensure that all information and issues are fully considered. We find that a focus on this phase can significantly minimize subsequent appeals. Following the reconsideration period, HMS will send a TNO/Final Audit Report to providers notifying them of DMA’s intent to recover the improper payment. Providers have the right to request an administrative appeal, consistent with the State’s administrative appeal regulations and timing. After cases pass the appeal response period, HMS generates the required deliverables for recovery or recoupment, consistent with DMA’s approved methodology and recovery of the improper payments. Types of Issues That HMS Can Review for DMA HMS has experience, expertise, and well-developed processes that span the full scope of Medicaid service types and improper payment issues. Exhibit E-25 summarizes by service area the types of audit issues that HMS has developed for other states and might be appropriate for DMA under the RAC contract. Exhibit E-25 of Issues That HMS Can Review for DMA Category Description Examples of HMS Success Inpatient Appropriate admission Inpatient coding (i.e., DRG) Bill audit Out-of-state reimbursement error Readmissions and transfers Never events/HACs Duplicate/overlapping payments (multiple types) Mother/baby duplicates Inpatient/outpatient unbundling Balance billing overpayments Financial review/credit balance Medicare deductible/ coinsurance errors Appropriate admission. This review returns approximately $50 million each year to one state client. Readmissions. HMS recently identified more than $67 million in potentially inappropriate readmission errors on behalf of one state. Credit balance. In 2010, HMS performed more than 4,000 Credit Balance Audits (onsite and desk) and recovered more than $110 million for clients through these audits. Many of the audits were safety net audits where another vendor was onsite at the hospital but missed the overpayment. Transfer issues. HMS has recovered more than $2 million for states related to transfer issues where we reviewed episodes of care with multiple institutional providers to ensure an appropriate payment of transfer rate.
Outpatient Duplicate/overlapping payments Unbundling Downcoding Radiology billing errors Anesthesia billing errors NCCI coding errors Bill audit ESRD issues HCD errors Financial review/credit balance Medicare coinsurance errors Outpatient/inpatient overlap and unbundling. In 2010, HMS recovered more than $3 million for outpatient/inpatient overlap- and unbundling-related issues. Where policy is not clear, we work with providers to help them understand the issue and the allowable and nonallowable exceptions to the rules. COB payment errors. HMS recovers more than $25 million annually in excess Medicaid payments where Medicare and other third parties have made a primary payment. Inappropriate billing for professional and ancillary services. To date in 2011, we have identified more than $50 million in overpayments related to upcoding of physician services on behalf of clients. ESRD. HMS has recovered more than $25 million in ESRD-related overpayments for clients. LTC Excess/duplicate days Patient-pay underreporting Bed hold days Date of Crossover billing errors LTC/hospice duplicate days Overlapping services included in per diem rate Financial review/credit balance Cost report auditing Cost of Care (COC). HMS recovers more than $20 million annually through LTC financial audits. The majority of recoveries are related to COC issues. Duplicate day payments for LTC, hospital, and hospice days. On behalf of one client, we recovered more than $6 million duplicate payments for hospice/LTC in 2010. Pharmacy Unit billing errors Duplicate payment/ early refill Return to stock overpayments OTB COB issues Duplicate pharmacy/ physician therapy 340b overpayments Fraud patterns In the past years, HMS has audited claims that have totaled more than $1 billion. Some audit findings have included duplicate claims, incorrect days’ supply or quantity submitted based on physician's direction, and early refill.
Ambulance Duplicate billing Medi-Medi duplicates Orphan transportation Unbundling Medicare COB/unbundling. For dual eligibles, HMS finds ambulance transports that should be covered under the hospital ER or inpatient stay separately billed to Medicaid. Orphan transport. HMS analyzes each recipient’s claims to identify transportation claims with no other medical services on that date. Behavioral Health Excess utilization Unit billing errors Nonqualified staff Billing for services not delivered Medical necessity issues Prior authorization discrepancies Services do not treatment plan Documentation issues HMS identified more than $10 million in overpayments in the first year of one behavioral health audit that we are conducting on behalf of a state Medicaid program for the following issues: nonqualified staff performing counseling, missing documentation, noncovered services, and medical necessity. Home and Community-Based Waiver Services Excess utilization Unit billing errors Nonqualified staff Billing for services not delivered Medical necessity issues Prior authorization discrepancies Services do not match treatment plan Documentation issues care. In nine months, HMS auditors identified more than $3 million in overpayments to Home and Community-Based Service providers in one southern Medicaid program for the following issues: missing documentation, excess hours, and noncovered services.