We’re going to start by saying just one word: AUDIT! Quick…what immediately went through your mind? Panic…Costs… or maybe, Confidence…or was it more of a physical reaction: Headaches…Gut Punch…Nausea…Sweating? That could all change very soon, thanks to several amendments recently proposed by the Texas Health and Human Services Commission!
So, what do these amendments mean for you? You know that feeling – if you've ever received a record request from a Medicaid MCO (Managed Care Organization), you know what a daunting task it can be to fulfill that request. And that’s assuming a best-case scenario! If you don't routinely audit your records, chart documentation and billed charges, we’re right back to sweating, nausea, stress...
And this could especially be true if you own a small practice. The standard request required you to first pull patient records for 50 CLAIM recipients, and THEN start the tedious review process, just to ensure all your ‘I’s are dotted and ‘T’'s are crossed before you even hand them over to the MCO – when the real tension begins. Depending upon the size of your existing patient base, this could amount to a complete internal review of up to 10-20 percent of your charts!
However, the OIG (Office of the Inspector General) has now proposed to cap the number of claims an MCO can request for a standard provider record audit. Based on this proposed amendment, an MCO would be able to request no more than 30 claims or 15 percent of a provider’s submitted Medicaid claims – whichever is the lesser number! This represents GREAT news for all providers, because it reduces a provider’s workload in preparation for an MCO review.
However, WellDent Compliance clients can skip the panic…nausea…well, you get the idea. We provide regular "in-house" audits of billed charges and chart documentation as part of our ongoing compliance services. And this makes it easier to spot “gaps” and allow you submit a corrected claim to show an act of provider good faith, and possibly mitigate or eliminate liability. However, if your practice does not have currently have protocols to routinely monitor these details, you should institute one immediately. And, if you DO have a system in place, these internal audits should continue to be routine within your practices. If any claims are found to be filed incorrectly, a corrected claim should be filed as soon as possible.
But, this new HHSC proposal could noticeably improve your life, when that inevitable MCO record audit request comes knocking at your practice door! FMI…see source article below.
Texas Health & Human Services Proposes Amendments To Fraud And Abuse Rules
by Joseph "Joe" Geraci, Jameson Sauseda | Husch Blackwell LLP
As provided in the Texas Register on March 22, 2019, the Texas Health and Human Services Commission (“HHSC”) has proposed several amendments to Title 1 of the Texas Administrative Code, which include amendments to the rules and procedures for preventing and investigating Medicaid fraud and abuse.
Managed Care Organizations
HHSC has proposed amendments to Sections 353.502 and 353.505 in effort to reflect the legislative changes as a result of House Bill 2379, which provided managed care organizations (“MCOs”) the ability to, under certain circumstances, retain a portion of the funds recovered by the HHSC Office of the Inspector General (“HHSC-OIG”) when fraud or abuse cases are referred to it by an MCO.
The proposed amendments include reducing the number of Medicaid recipient claims an MCO must review from 50 to 30 recipients or 15 percent of a provider’s claims. In addition, an MCO is required to notify HHSC-OIG of possible acts of waste, abuse, or fraud within 30 working days of the completion of an investigation. MCOs must also include specific documentation in their report to HHSC-OIG, including, among other documents, the provider’s credentialing documents, the complete investigative file as well as a summary of past investigations. The proposed amendments also attempt to simplify the existing language of Section 353.505 to improve coordination between MCOs and the HHSC-OIG regarding the referrals and recovery process of Medicaid fraud and abuse claims.