Medicaid and the Risks to Providers Ivan J. Punchatz, Esq. - - PowerPoint PPT Presentation
Medicaid and the Risks to Providers Ivan J. Punchatz, Esq. Shareholder, Healthcare Section Buchanan Ingersoll & Rooney Rich Skorupski, CIC, CRM, CPCU Senior Vice President Meeker Sharkey & Hurley Medicaid Background Medicaid
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– Physician services – Lab and x-ray services – Inpatient hospital – Outpatient hospital – EPSDT for individuals under 21 – Family planning – Rural and federally qualified health care (FXHS) services – Nurse midwife services – Nursing facility (NF) services for individuals 21 and over – Home health for certain populations
– Essential Health Benefits (“Benchmark Coverage” and “Benchmark Equivalent Coverage”)
– Prescription drugs – Clinic services – Dental services, dentures – Physical therapy and rehab – Prosthetic devices, eyeglasses – Primary care case management – Institutions for individuals with intellectual disabilities, formerly intermediate care facilities for the mentally retard (ICF/MR) services – Inpatient psychiatric care for individuals under 21 – Personal care services – Alcohol and drug treatment
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Source: The Kaiser Commission on Medicaid and the Uninsured: Medicaid A Primer 2013
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Source: The Kaiser Commission on Medicaid and the Uninsured: Medicaid A Primer 2013
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Supplement are: – Prior authorization forms and instructions – Information for the proper completion and submission of claim forms – Procedure to follow when claims are rejected and returned to the provider by the Fiscal Agent during the adjudication process – Third-party liability verification – Procedure for submitting crossover claims and examples of timely submission of claims – Electronic media claims (EMC) submission – Remittance Advice Statements – Procedures for Electronic Funds Transfer (EFT) – Adjustments for overpayment of claims and adjustments by Medicare – Procedure to follow when a claim is paid in error (voids) – Procedure for inquiries about claims – Procedure for ordering forms – Information about provider services – Item-by-item instructions for completing the claim form and other forms.
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– Maintain and follow standards, qualifications, regulations, policies, procedures, etc. – Develop strategies in collaboration with the individual receiving services to assist the individual in reaching his/her outcomes. – Complete and maintain documentation as required. – Claim for services according to Medicaid (Molina) standards and guidance. – Provide services and supports within the parameters indicated in the ISP. – Become familiar with the individual’s vision, outcomes, needs, etc. and provide services and supports accordingly. – Participate as a member of the Planning Team when identified in that role by the individual. – Complete and submit reporting documents as required. – Comply with monitoring, auditing, quality assurance measures conducted by DDD and/or Medicaid/Molina. – Comply with policies, standards, and procedures specific to the service being provided as described for each service in Section 17.
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– The delivery of service must be properly documented along with any deliverable documents necessary to substantiate the claim in the case of an audit. Services may have specific deliverable documents (such as strategies, time sheets, behavior plans) relevant to delivery of that service. Details about these documents are provided in Section 17. – The service that was provided must have a valid prior authorization, – The claim must include participant information and service information (such as Medicaid ID, diagnosis, procedure code, rate etc.) which can be found within the service plan and service detail report,
(www.njmmis.com) or through a software solution which can perform bulk electronic claim submission.
provided by Molina Health Care. Molina provider services can be reached by calling 800.776.6334 or on the NJMMIS website through the option “Contact Provider Services.”
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– Service providers are required to check that staff hired, Board of Directors and contracted vendors utilized are not excluded from working with individuals with developmental disabilities or within a Medicaid provider agency. These checks include, but are not limited to:
frequently than ongoing monthly checks.
OIG has the authority to exclude individuals and entities from Federally funded health care programs and maintains a list of all currently excluded individuals and entities called the List of Excluded Individuals and Entities (LEIE). Anyone who hires an individual or entity on the LEIE may be subject to civil monetary
Administration Excluded Parties List System (GSA EPLS)] - The Excluded Parties List System is an electronic, web-based system that identifies those parties excluded from receiving Federal contracts, certain subcontracts, and certain types of Federal financial and non-financial assistance and benefits. http://www.sam.gov.
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– Ongoing evaluation of service providers will occur to ensure compliance with Division standards and Medicaid claiming either via routine audits or other
inspections, reviews of policies and procedures, trend analysis or other methods as deemed appropriate by the Division’s Quality Improvement Office. All service providers will be subject to both fiscal and programmatic reviews and audits on a regular basis by both Medicaid and the Division. – Day Habilitation programs must be certified, which will require formal reviews and on-site inspections. See Section 17.7.3 for detailed information. – Residential programs will continue to be licensed and subject to published licensing regulations. Current requirements can be found at: http://www.state.nj.us/humanservices/ool/licensing/.
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– Written policies and procedures. – Compliance professionals (i.e., Chief Compliance Officer & Committee).
individuals whom the facility knew, or should have known through the exercise of due diligence, had a propensity to engage in criminal, civil, and administrative violations. – Effective training of all executives and employees. – Effective communication process/mechanism for reporting (allowing for anonymous and good faith reporting of potential compliance issues as they are identified). – Internal monitoring (internal/external audits). – Enforcement of standards/disciplinary policies for failing to report suspected problems; engaging in non-compliant behavior; encouraging, directing, facilitating or permitting either actively or passively non-compliant behavior. – Prompt response/corrective actions.
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– MEDEFENSE™ PLUS – Defense costs and civil fines and penalties coverage for Billing Errors, HIPAA, EMTALA and Stark proceedings. – Standalone HIPAA Protector – Defense costs and civil fines and penalties coverage for governmental HIPAA proceedings. – Full Prior Acts available. – Broad definition of Insured. – Broad definition of Billing Errors Proceedings to include both governmental and commercial payer audits and investigations, qui tam plaintiffs or voluntary self- disclosure. – Selection of counsel available. – Sub-limit available for Medical Board Proceeding defense cost reimbursement. – Payment for shadow audits.
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