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Oregon Medicaid Recovery Audits

Oregon Medicaid Recovery Audits. September 14, 2012. Speakers. Fritz Jenkins, Oregon Department of Human Services Angela Torres, HMS Oregon Program Director Michele Mallery, HMS Oregon Program Manager. 2. Agenda. Introductions HMS Overview Federal and State regulations governing RACs

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Oregon Medicaid Recovery Audits

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  1. Oregon Medicaid Recovery Audits September 14, 2012

  2. Speakers • Fritz Jenkins, Oregon Department of Human Services • Angela Torres, HMS Oregon Program Director • Michele Mallery, HMS Oregon Program Manager 2

  3. Agenda • Introductions • HMS Overview • Federal and State regulations governing RACs • HMS RAC Processes • HMS Provider Portal • Questions & Answers

  4. HMS Overview

  5. HMS Overview Established in 1974 Serving Medicaid since 1985 Publicly traded since 1992(NASDAQ:HMSY) 36 offices nationwide 2,500 employees www.hms.com

  6. To improve the effectiveness of the healthcare system We are experts in cost management, focused on delivering comprehensive solutions that allow healthcare dollars to reach more people, save taxpayer money, and make the system work better for everyone. Our Mission

  7. State Programs 40+ State Medicaid Programs State Employee Benefit Plans AIDS Drug Assistance Program and State Pharmacy Assistance Program Child Support Agencies Federal Programs Centers for Medicare and Medicaid Services Veterans Administration Commercial Programs Managed Care Organizations Pharmacy Benefit Managers Who We Serve

  8. What We Do We help ensure that claims are paid correctly (Program Integrity) and by the responsible party (Coordination of Benefits) We provide cost containment services for healthcare payers

  9. HMS Experience

  10. Federal and State Regulations

  11. Recovery Audit Contracts (RAC) The Patient Protection and Affordable Care Act of 2010 requires the Recovery Audit Contract Program to be expanded to Medicaid Programs. Background: Medicare RACs • Medicare RACs were mandated by Congress • Pilot RACs 2005 – 2008 in three states—FL, NY, CA • Follow-up RAC Contracts were issued late 2008 with 2009 implementation • Scope was reduced • Operating protocols were tightened • Qualifications made more rigorous PPACA 6411

  12. Medicare RACs vs. Medicaid RACs

  13. HMS RAC and DHS PAU Similarities & Differences *All HMS audits and findings are PAU approved

  14. Oregon Medicaid RAC Project Status • RAC contract executed September 2011 • Audits rolling out beginning July 2012 • Number of audits • Audit frequency • Medical record request limits

  15. HMS RAC Processes

  16. Use of Medicaid Specific Data • HMS analyzes claims to identify payment or billing errors • “One size does not fit all” • Processes that work in the commercial or Medicare environment cannot be directly applied to Medicaid • HMS customizes our analyses and recovery processes to take into consideration Oregon specific billing regulations and reimbursement policies • HMS validates overpayments prior to recoupment

  17. Meeting and Exceeding RAC Final Rules

  18. Recovery Audit Review Process • Program Analysis • Work in Progress • Data Mining • Review/Approval Analysis And Targeting • Provider Contact • Request Letters • Tracking/follow up • Electronic Records Record Request • RN/Coder Review • Physician Referral • Overpayment Calculation • QA and Client Review • Preliminary Report Review/Audit • Final Audit Report • QA/Certified Mailing • Reconsideration/Appeal • Recovery Support Notification and Recovery • Notification Letter • Provider Association Meetings • Program Recommendations • Newsletter/Website Education, Process Improvement

  19. Oregon DHS Appeals Process OAR 407-120-1505

  20. Provider Resources

  21. HMS Provider Portal What is the Provider Portal? • Secure data environment • Real-time access to overpayment recovery projects • On-demand reports for effective management • Automates communication with providers

  22. Provider Portal Benefits • Allows for real-time access to recovery audit claims information • Expedites provider involvement in the process • Automates communication with providers • Ensures current, accurate provider demographic data to HMS

  23. Registering for HMS’s Provider Portal • https://ecenter.hmsy.com

  24. User Registration

  25. My HMS Home Page

  26. Cycle Search

  27. Recipient Search Screen

  28. Claim Search Screen

  29. Claim/AR Update

  30. Questions?

  31. Contacts Angela Torres Program Director 208.639.8225 atorres@hms.com Michele Mallery Program Manager 646.637.5913 michele.mallery@hms.com

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