Partnering with New Mexico for

Medicaid Recovery Audit Services

New Mexico Provider Associations and Providers in

Upcoming Audits

September 19, 2013

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Agenda

» HMS Overview

» What is Medicaid RAC

» New Mexico RAC Overview

» Provider Service & Protocols

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Our Mission & Vision

»» HMS’s Mission We work passionately to increase

the value of the healthcare system for payors and

sponsors. Our solutions drive payment and clinical

accuracy and quality so that healthcare dollars can

benefit more people.

» HMS’s Vision To power the healthcare system with

integrity.

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HMS Holdings Credentials

» Serving government healthcare programs since 1985

» 45 Medicaid Program integrity contracts, including over 30 Medicaid RACs

» In 2012, HMS recovered over $3.2B on behalf of our clients

» Medicare Program Integrity, Midwest Program Safeguard Contractor

» Medicare RAC

HMS is a strategic source for innovative cost containment solutions for

healthcare industry clients

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01. WHAT IS MEDICAID RAC

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HMS’s Medicaid RAC Standards

Reduce provider abrasion, customer service, and limit administrative costs

Possess in depth knowledge of NM Medicaid policies, regulations and MMIS processes

Maintain an understanding of the state’s operating environment – political, provider associations, agency goals

Experienced in coordinating with other state audit entities

Have established processes for 1) receiving and formatting Medicaid data and 2) proven provider relations

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Overview of Review Process

Analysis

And Targeting

Review/Audit

• Program Analysis

• Data Mining/Scenario Design

• State Approval

Record Request

• Provider Contact

• Record Request/Receipt

• Tracking/follow up

• RN/Certified Coder Review

• Physician Referral

• QA and Client Review/Approval

Notification

and Recovery

• Notification Letter

• Provider Reconsideration/Appeal

• Recovery Support

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Meeting and Exceeding RAC Final Rules

Credentials

• Certified Coders

• Registered Nurse Reviewers

• Panel of Licensed Physicians

Customer Service

•Dedicated Toll-free Number

•NM Trained Customer Services Representatives

•Web-Based Provider Portal

Coordination

•With Federal or Other State Agencies

•With Previous SURS/TPL Review Efforts

•With Medicare RAC, Medicaid Fraud Control Unit (MFCU), etc.

Transparency

•Perform Provider Address Checks

•Detailed Recovery Letters

02. NEW MEXICO RAC OVERVIEW

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Types of Reviews

1) Automated Review is applied in scenarios where

improper payments can be identified based on data

analysis alone

2) Complex Review is required when data analysis

identifies a potential improper payment that requires

record review for validation

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NM RAC Specifics

» Three Year Look Back Period from Original Paid Date

» No State (NM) Limit Set on Records Request

» Record Submission Options:

• Secure Web submission

• Mail

• Fax (877) 829-9080

» Provider Resources

• Questions Call Provider Services - (855) 534-2237

• Web portal - Status on Claims

• Website:

•HMS-NM RAC P.O. Box 168327

•Irving, TX

•75016-8327

•HMS-NM RAC P.O. Box 168327

•Irving, TX

•75016-8327

HMS-NM RAC P.O.

Box 168327 Irving,

TX 75016-8327

Timing is Everything!

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Automated

30 Days to respond to Preliminary Findings of Fact

Agree send check

Disagree, respond in 30 days to HMS

Continued disagreement 30 days to submit to HMS to forward to HSD for Provider Hearing

Complex

30 Days to submit medical records (electronic, mail or fax)

60 Days for HMS to review

30 Days to respond to Preliminary findings of fact

Agree send check

Disagree, respond to HMS in 30 days

Continued disagreement 30 days to submit to HMS to forward to HSD for Provider Hearing

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Technical Denials

Day 1 • Request sent to provider following initial mailing

Day 10 • Follow-up call made to provider following initial mailing

Day 30 • Technical Finding (denial) letter sent to provider 30 days

from the initial mailing if the provider fails to respond

Day 45 • Request for Recovery sent to Provider, if the Provider

Fails to Respond

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Appeal Information

» Level #1:If you are in disagreement, send your response and additional

documentation to HMS, you will receive a response either upholding or

denying

» Level #2:If you have received a denial and are in disagreement, send a copy

of your denial, your response and additional information to HMS. This will

be forwarded to HSD for the Provider Hearing process

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Recovery Method

Make checks payable to:

New Mexico Human Services Department HSD

P.O. Box 25784

Albuquerque, New Mexico 87125-5784

» By Check Only

» No Provider Recoupments

» Send Check to the following address:

NM Provider

P.O. Box 12345

Albuquerque, New Mexico 11111-1111

03. PROVIDER SERVICES & PORTAL

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Provider Portal

» HMS NM Provider web site: http://www.hsd.state.nm.us/mad/

About HMS

NM RAC Provider Information

& HMS Contact Information

» The Provider Portal:

Secure website that allows providers the ability to manage their RAC reviews

More than 15,000 providers currently use HMS’s Provider Portal

Contact information can be updated by providers

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Live Demo

» Provider Portal

• What it’s used for

• Functionality

• How to Check Claims Status

• Documentation submission

» How to sign up &

User guide https://ecenter.hmsy.com

Contact Information

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HMS Account Team:

Cristhian Bermudez, Arizona Program Director Phone: (602) 954-8380 x 108 email: cbermudez@hms.com Anna Annon Arizona Program Manager Phone: (505) 470-5593 x 107 email: anna.annon@hms.com HMS Provider Services Team p: (855) 534-2237 f: (877) 829-9080