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Georgia Medicaid Program Integrity and RAC: What You Can Expect in 2014

Georgia Medicaid Program Integrity and RAC: What You Can Expect in 2014. Presentation To The HomeTown Health 14 th Annual Fall Conference Calloway gardens ga , November 14, 2013. MEDICAID RAC: OVERVIEW. Perform audits to identify mispayments Includes both FFS and CMO claims

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Georgia Medicaid Program Integrity and RAC: What You Can Expect in 2014

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  1. Georgia Medicaid Program Integrity and RAC: What You Can Expect in 2014 Presentation To The HomeTown Health 14th Annual Fall Conference Calloway gardens ga, November 14, 2013

  2. MEDICAID RAC: OVERVIEW • Perform audits to identify mispayments • Includes both FFS and CMO claims • Five-year “look back” • Medical director and certified coders required • Provider education and outreach • Coordination with other audit contractors and programs • Limitation on medical record requests • Administrative review process

  3. mYers and stauffer LC • CPA firm with 18 offices nationwide • Healthcare consulting, auditing and reimbursement services • Strictly government clients (45 States and Fed government) • Selected as Georgia Medicaid RAC effective April 2, 2012

  4. MSLC georgiarac team • Project Director – Michael Johnson, CPA and CFE • Project Manager – Scott Smeal, JD • Medical Director – Joel Goldstein, MD • Analysts, Nurses, Coders, Data Analysts • Additional Staff as Needed

  5. RAC AUDITS • Developed in consultation with and subject to the approval of the DCH IG • Three basic types: • “Automated” or claims-based, without medical records • “Complex” with records review (desk or onsite) • Self-audits • Unbiased review to determine mispayments (both overpayments and underpayments)

  6. Audit procedures • Complex audits typically begin with request for records • Initial Findings Letter • Provider can agree or request administrative review • Final Decision • Administrative Appeal in accordance with Chapter 500, Part I, Policies and Procedures for Medicaid/Peachcare for Kids™

  7. Fraud referrals • MSLC required by contract and Federal law to refer instances of suspected fraud • Referrals are made to DCH Deputy Inspector General • DCH decides to refer to MFCU and/or other appropriate Federal and/or State law enforcement or regulatory agencies

  8. Provider Education and Outreach • Toll-Free Number (855) 201-4570 • MSLC RAC website: http://georgiamedicaidrac.mslc.com • Frequently asked Q & A • Points of Contact • Audit Policies and Protocols • Audit Agenda • News and Updates

  9. RAC Provider Relations (RPR) Advisory Committee • Established to promote provider input about general RAC issues • 15 members, including 4 from DCH, 4 from MSLC and 7 from the provider community • Quarterly meetings • One-year term • No compensation

  10. Active audits • Hospital transfer pricing • Patient liability • Fair rental value (FRV) • Neonatal Intensive Care Unit (NICU) services • Hospital outpatient related to inpatient • Physician services: allergy, drug screen, global services

  11. Preliminary audits • DME • DRG validation • Home health services • Hospice • Duplicate payments • NCCI/MUE

  12. Myers and stauffer LC Located in Georgia-Pacific Center at 133 Peachtree Street, NE – Suite 3150 Atlanta, GA 30303 (404) 524-0775 (404) 524-0782 (FAX) Toll-Free (855) 201-4570 Michael D. Johnson or Scott A. Smeal

  13. Questions?

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