BEFORE THE ADMINISTRATIVE HEARING COMMISSION STATE …€¦ · 13 CSR 70-3.030(5) provides that the...

BEFORE THE ADMINISTRATIVE HEARING COMMISSION

STATE OF MISSOURI

Maxim Healthcare Services, Inc. ) 11330 Olive Blvd, Suite 200 ) St. Louis, MO 63141 ) (314) 569-3935, )

) Petitioner, )

) vs. ) Case No.:

) Missouri Department of Social Services ) P. 0. Box 6500 ) Jefferson City, Missouri 65102 ) (573) 751-4815, )

) Missouri Medicaid Audit and ) Compliance Unit ) P.O. Box 6500 ) Jefferson City, Missouri 65102 ) (573) 751-3399, )

) and )

) Division of MO HealthNet ) 615 Howerton Court ) Jefferson City, Missouri 65109 ) (573) 751-6922, )

) Respondents. )

COMPLAINT

FILED MAY I 3 2014

ADMINISTRATIVE HEARING COMMISSION

----

COMES NOW Petitioner Maxim Healthcare Services, Inc., by and through its

attorneys, and for its Complaint states as follows:

1 JEF-263428-3

PARTIES

1. Petitioner Maxim Healthcare Services, Inc. ("Petitioner") is a Maryland

corporation in good standing with a certificate of authority as a foreign corporation issued

under the laws of the state of Missouri. Its primary place of business in Missouri is at

. 11330 Olive Blvd, Suite 200, St. Louis, MO 63141.

2. Respondent Missouri Department of Social Services ("Respondent DOSS")

is an agency of the State of Missouri in which Missouri Medicaid Audit and Compliance

Unit and the MO HealthNet Division are contained. Respondent DOSS is the single state

agency in the State of Missouri with responsibility to administer the MO HealthNet

· reimbursement program.

3. Respondent Missouri Medicaid Audit and Compliance Unit ("Respondent

MMAC") is a unit within the Office of Director of Respondent DOSS. Respondent

MMAC is the unit within Respondent DOSS which manages provider enrollment and

audit services for the MO HealthNet program.

4. Respondent MO HealthNet Division, formerly known as the Division of

Medical Services ("Respondent Division"), is an agency of the State of Missouri and a

division of Respondent DOSS.

JURISDICTION

5. This cause of action is filed under§ 208.156, RSMo 2000 and§ 621.055,

RSMo Supp. 2012.

6. The amount in dispute is in excess of $500.00.

2 JEF-263428-3

7. The Administrative Hearing Commission has jurisdiction over the matters

and parties which are the subject of this Complaint.

FACTUAL BACKGROUND

8. At all times relevant herein, Petitioner had valid agreements to participate

in the Title XIX MO HealthNet (formerly known as Medicaid) reimbursement program.

Pe~itioner's provider numbers are 1346416492 (Personal Care Program provider number)

and 1437325586 (Aged and Disabled Waiver program provider number).

9. Petitioner provides personal care services through the MO HealthNet

Personal Care program. Petitioner also provides homemaker, chore, and respite care

services through the MO HealthNet Aged and Disabled Waiver program. These services

are provided to seniors and adults with disabilities that enable the individuals to remain in

the least restrictive environment.

10. Respondent MMAC sent two letters dated April 15, 2014 (the "Decision

Letters") to Petitioner, copies of which are attached as Exhibit A and Exhibit B to this

Complaint and incorporated by reference herein. 1

11. In the Decision Letters, Respondent MMAC. seeks reimbursement from

Petitioner in the total amount of $74,088.37 for alleged overpayments of MO HealthNet

payments to Petitioner. The decision letter attached at Exhibit A seeks reimbursement

from Petitioner, as a Personal Care Program provider, in the amount of $64,909.75. The

1 Attachment B fo the Decision Letters are not included as a part of Exhibit A and Exhibit B because they include protected health information ("PHI") of individuals who are eligible for services for which Respondents make payments and public disclosure of such PHI is not permitted under the Health Insurance Portability and Accountability Act of 1996 and related regulations. The information in Attachment B to the Decision Letters is known to the Respondents. If necessary to the disposition of the i:riatter or upon request of the Commission or Respondents, Petitioner will provide a copy of the documents under seal or with such other protections as the Commission may deem appropriate to protect the confidentiality of the PHI.

3 JEF-263428-3

decision letter attached at Exhibit B seeks reimbursement from Petitioner, as an Aged

·and Disabled Waiver program provider, in the amount of $9,178.62.

12. The Decision Letters each state that a post-payment review of Petitioner's

MO HealthNet claims identified billing errors, and that the Attachment A to the Decision

Letters is an"[ o ]utline of incorrect billing procedures ( errors identified)[.]"

13. Attachment A to each of the Decision Letters identifies three errors by

letter - Error A, Error B, and Error C.

14. On Exhibit A, the vast majority of claims were allegedly overpaid as a

result of Error B, with only $139.51 of the alleged overpayment resulting from Errors A

andC.

15. On Exhibit B, the vast majority of claims were allegedly overpaid as a

result of Error B, with only $15.12 of the alleged overpayment resulting from Error A.

Although Error C is listed on Attachment A to Exhibit B as an error discovered during

the post-payment review, none of the alleged overpayment was associated with Error C.

16. The error indicated as "Error B" on Attachment A to the Decision Letters is

"[t]here is no daily participant's signature on the time sheet." In support of this error,

both Decision Letters cite to 13 C.S.R. 70-91.010(4)(A) 2. F and§ 13.7.D(l) 6 of the MO

HealthNet Personal Care Provider Manual.

17. To comply with the participant signature requirement, Petitioner designed a

Weekly Note form: This Weekly Note form has a column for every day of the week in

which Petitioner's employees identify the time at which they arrived at the participant's

home, the time at which they left the participant's home, and the tasks that were

4 JEF-263428-3

completed during the visit. At the bottom of eacp column is a space for the employee's

initials and the patient's and/or family caregiver's initials. At the bottom of the Weekly

Note form is a space for the patient's and/or family caregiver's full signature. The full

signature is obtained on the last day the participant receives services for the week.

18. In addition to the Weekly Note, Petitioner verifies employee visits by

conducting periodic supervisory visits, assessments, and customer satisfaction surveys.

19. For each of the participants identified in the Decision Letters with an Error

B, Petitioner has a Weekly Note form that includes the patient's or family caregiver's

initials in each relevant column and includes the patient's or family caregiver's full

signature at the bottom of the form.

20. The regulation and provider manual cited in the Decision Letters apply only

to the MO HealthN et Personal Care Program. The cited regulation and provider manual

do not apply to the Aged and Disabled Waiver program, under which Petitioner provided

homemaker, chore, and respite care services, which are the services at issue in Exhibit B.

Separate regulations and a different provider manual govern providers under the Aged

and Disabled Waiver program.

21. Exhibit A and Exhibit B each state that Petitioner may appeal the

determinati~ns in the Decision Letters to the Administrative Hearing Commission.

Petitioner herein appeals the decision of the Respondents in Exhibit A and ·Exhibit B.

22. This Complaint is timely filed and seeks a hearing before the

Administrative Hearing Commission from the decisions and determinations of

Respondents in the Decision Letters dated April 15, 2014 (Exhibit A and Exhibit B).

5 JEF-263428-3

CAUSES OF ACTION

I. COUNT I (abuse of discretion for all determinations made in the

Decision Letters):

23. Petitioner incorporates by reference paragraphs 1-22 as though fully set

forth herein.

24. 13 CSR 70-3.030(5) provides that the MO HealthNet agency "shall"

consider various factors in determining whether to issue a sanction against a provider of

services. The mandatory considerations outlined in 13 CSR 70-3.030(5) provide:

JEF-263428-3

(A) The decision as to the sanction to be imposed shall be at the

discretion of the MO HealthNet agency. The following factors shall be

considered in determining the sanction(s) to be imposed:

(1) Seriousness of the offense(s)- The state agency shall

consider the seriousness of the offense(s) including, but not limited

to, whether or not an overpayment (that is, financial harm) occurred ·

to the program, whether substandard services were rendered to MO

HealthNet participants, or circumstances were such that the

provider's behavior could have caused or contributed to inadequate

or dangerous medical care for any patient(s), or a combination of

these. Violation of pharmacy laws or rules, practices potentially

dangerous to patients and fraud are to be considered particularly

serious;

6

JEF-263428-3

(2) Extent of violations - The state MO HealthNet agency

shall consider the extent of the violations as measured by, but not

limited to, the number of patients· involved, the number of MO

HealthNet claims involved, the number of dollars identified in any

overpayment and the length of time over which the violations

occurred. The MO HealthNet agency may calculate an overpayment

or impose sanctions under this rule by reviewing records pertaining

to all or part of a provider's MO HealthNet claims. When records

are examined pertaining to part of a provider's MO HealthNet

claims, no random selection process in choosing the claims for

review as set forth in 13 CSR 70-3.130 need be utilized by the MO

HealthNet agency. But, if the random selection process is not used,

the MO HealthNet agency may not construe violations found in the

partial review to be an indication that the extent of the violations in

any unreviewed claims would exist to the same or greater extent;

(3) History of prior violations - The state agency shall

consider whether or not the provider has been given notice of prior

violations 9fthis rule or other program policies. If the provider has

received notice and has failed to correct the deficiencies or has

resumed the deficient performance, a history shall be given

substantial weight supporting the ag·ency's decision to invoke

sanctions. If the history includes prior imposition of sanction, the

7

JEF-263428-3

agency should not apply. a lesser sanction in the second case, even if

the subsequent violations are of a different nature;

( 4) Prior imposition of sanctions - The MO HealthN et

agency shall consider more severe sanctions in cases where a

provider has been subject to sanctions by the MO HealthNet

program, any other governmental medical program, Medicare, or

exclusion by any private medical insurance carriers for misconduct

in billing or professional practice. Restricted o! limited participation

in compromise after being notified or a more severe sanction should

be considered as a prior imposition of a sanction for the purpose of

this subsection;

(5) Prior provision of provider education- In cases where

sanctions are being considered for billing deficiencies only, the MO

HealthNet agency may mitigate its sanction_ if it determines that

prior provider education was not provided. In cases where sanctions

are being considered for billing deficiencies only and prior provider

education has been given, prior provider education followed by a

repetition of the same billing deficiencies shall weigh heavily in

support of the medical agency's decision to invoke severe sanctions;

and

( 6) Actions taken or recommended by peer review groups,

licensing boards, or Professional Review Organizations (PRO) or

8

utilization review committees - Actions or recommendations by a

provider's peers shall be considered as serious if they involved a

determination that the provider has kept or allowed to be kept,

substandard medical records, negligently or carelessly performed

treatment or services, or, in the case of licensing boards, placed the

provider under restrictions or on probation.

_25. The Decision Letters in this case do not explain or otherwise provide notice

of the reasoning or factors, if any, that Respondents relied on in imposing the sanction of

recoupment for the alleged violations. Because of Respondents' failure to give notice to

Petitioner of their reasoning and the factors that they considered in imposing the sanction

of 100% full recoupment for the alleged violations, Respondents did not provide

Petitioner a meaningful notice and, hence, a fair opportunity for a meaningful hearing.

Respondents have thereby acted in an arbitrary, capricious, or unreasonable manner in

violation of Petitioner's rights guaranteed under 'the Fifth and Fourteenth Amendments to

. the United States Constitution and Article I, Section 10 of the Missouri Constitution.

26. Upon information and belief, Respondents violated 13 CSR 70-3.030(5) by

reaching the determinations outlined in the Decision Letters without considering any of

the six factors required to be considered under the regulation.

27. Additionally, none of these mandatory considerations weigh in favor of any

sanction here, and such considerations certainly do not support the sanction issued by

Respondents, i.e. the 100 percent recovery of such payments from Petitioner for those

clainis for services actually provided beneficiaries.

9 JEF-263428-3

28. Petitioner provided services that are the subject of the Decision Letters,

these services were allowable, necessary, and reasonable, and Respondents' participants

received the benefit of those services.

29. Accordingly, the decisions and determinations of Respondents in the

Decision Letters are arbitrary, capricious, and not supported by law, nor are such

determinations supported by Respondents mandatory guidelines, which upon information

and belief Respondents ignored or did not otherwise follow.

II. COUNT II ( other grounds for appeal of all determinations made in the

Decision Letters):

30. Petitioner incorporates by reference paragraphs 1-29 as though fully set

forth herein.

31. The action of Respondents in issuing the decisions and determinations in

the Decision Letters to Petitioner are also improper, unlawful, and/or not factually

supported for one or more· of the following reasons:

a. Petitioner did not violate any of the cited MO HealthNet program

participation requirements.

b. The cited program participation requirements are vague.

c. The alleged violations of the MO HealthN et program do not exist

and did not exist at the time of the audit conducted by Respondent MMAC.

d. The decisions and determinations of Respondents in the Decision

Letters are arbitrary, capricious or unreasonable, and not supported by law.

10 JEF-263428-3

e. Petitioner is and was at all applicable times herein in substantial

compliance with the requirements of participation in the MO HealthNet reimbursement

program administered by Respondents.

f. Respondents' decision to seek reimbursement of 100 percent of the

claims identified in the Decision Letters is not and cannot be supported by competent and

substantial evidence, and is arbitrary, capricious and/or unreasonable.

g. Reduction of Respondents' prior reimbursements pursuant to the

Decision Letters will result in reimbursement which is less than reasonable in violation of

the provisions of Section 208.152.1, RSMo. Supp. 2012.

h. Respondents, by benefiting from the care provided by Petitioner and

costs Petitioner incurred, but failing to pay for the same, are denying Petitioner its

property without due process of law in violation of the United States and Missouri

Constitutions.

1. Respondents have utilized standards for determining allowable,

reasonable, and necess_ary costs which are beyond their jurisdiction to use.

j. In ~he Decision Letters, Respondents have made adjustments to

reimbursements previously paid for services provided by Petitioner which are

unsupported by statute or by any duly promulgated regulation of Respondents.

k. Respondents' decision to deny MO HealthNet payments to

Petitioner is not and cannot be supported by_ competent and substantial evidence.

11 JEF-263428-3

1. Respondents violated requirements of Chapter 208 in their

enforcement action against Petitioner; such violation resulted in prejudice to Petitioner

and the enforcement action is therefore invalid and void. ·

III. COUNT III (unlawful use of unpromulgated rules):

32. -Petitioner incorporates by reference paragraphs 1-31 (including all

subparts) as though fully set forth herein.

33. Section 536.010(6), RSMo Supp. 2012 defines a "rule" as:

[E]ach agency statement of general applicability that implements, interprets or prescribes law or policy, or that describes the organization, procedure, or practice requirements of any agency.

34. Section 536.021.7, RSMo. states, in part:

[ A ]ny rule, or amendment or recision thereof, shall be void unless made in accordance with the provisions of this section.

35. To the extent that Respondents have an unpromulgated policy of always

seeking 100 percent recoupment of alleged overpayments, the unpromulgated policy

conflicts with 13 CSR 70-3.030( 4) and (5) which provide that the decision to impose

sanctions is discretionary and depends on the evaluation of six separate factors.

36. Moreover, the unpromulgated policy of always seeking 100 percent

recoupment of overpayments is a "statement of general applicability that implements,

interprets, or prescribes law or policy," and, therefore, constitutes a "rule" within the

meaning of section 536.010(6), RSMo Supp. 2012, and is null, void, and unenforceable

12 JEF-263428-3

because it was not promulgated pursuant to section 536_.021, RSMo Supp. 2012. Section

536.021.7, RSMo Supp. 2012.

3 7. Thus, to the extent that the determinations in the Decision Letters are based

on this unpromulgated policy, the Decision Letters are null, void, and unenforceable.

Section 536.021.7, RSMo Supp. 2012.

38. Section 536.021.9 RSMo. Supp. 2012 provides:

If it is found in a contested case by an administrative or judicial fact finder that a state agency's action was based upon a statement of general applicability which should have been adopted as a rule, as required by sections 536.010 to 536.050, and that agency was put on notice in writing of such deficiency pri~r to the administrative or judicial hearing on such matter, then the administrative or judicial fact finder shall award the prevailing nonstate agency party its reasonable attorney's fees incurred prior to tlie award, not to exceed the amount in controversy in the original action. This award shall constitute a reviewable order. If a state agency in a contested case grants the relief sought by the nonstate party prior to a finding by an administrative or judicial fact finder that the agency's action was based on a statement of general applicability which should have been adopted as a rule, but was not, then the affected party may bring an action in the circuit court of Cole County for the nonstate party's reasonable attorney's fees incurred prior to the relief being granted, not to exceed the amount in controversy in the original action.

39. This Complaint is notice to Respondents under Section 536.021.9 RSMo

Supp. 2012. Additionally, Respondents have previously been put on notice of the

unlawfulness of the unpromulgated policy described herein. See Complaint at 11-12,

Allen v. Dept. of Social Services, AHC Case No. 10-0925 SP (May 25, 2010).

13 JEF-263428-3

IV. COUNT IV (Respondents seek repayment of claims for which

retitioner did not receive payment)

40. Petitioner incorporates by reference paragraphs 1-39 (including all


41. Respondents seekrecoupment of$122.85 for three separate claims

identified on'page 43 of 66 of Attachment B to Exhibit A with "Error C."

42. Petitioner originally received payment for these claims on July 12, 2013,

but on November 8, 2013, these claims were reversed by Petitioner, resulting in the

return of the $122.85 to MO HealthNet.

4 3. Petitioner's decision to seek recoupment of any alleged overpayment

associated with these claims is thus arbitrary, capricious, or unreasonable, and not

supported by competent and substantial evidence.

V. COUNT V ( cited regulations do not apply to Aged and Disabled

Waiver program)

44. Petitioner incorporates by reference paragraphs 1-43 (including all


45. In the Decision Letter, Attachment A, paragraphs A and B, attached hereto

as Exhibit B, Respondents cite to regulations and manual provisions inapplicable to the

Aged and Disabled Waiver program. The claims involved in the alleged errors were all

filed under the Aged and Disabled Waiver program.

46. Therefore, Petitioner could not have violated these regulations and manual

provisions in its capacity as an Aged and Disabled Waiver program provider and the

14 JEF-263428-3

claims submitted by Petitioner for homemaker, chore, and respite care services provided

pursuant to the Aged and Disabled Waiver program are not overpayments by reason of

Petitioner's alleged violation of inapplicable regulations and manual provisions.

WHEREFORE, Petitioner prays the Administrative Hearing Commission for the

following relief:

A. Its decision, ruling, finding, and order that the determinations and decisions

of Respondents set out in the Decision Letters were in error as aforesaid, and ordering

Respondents to set aside the determinations and decisions of Respondents set out in the

Decision Letters. Petitioner respectfully requests that this Commission consider the facts

and circumstances and independently determine an appropriate action, if any;

B. Its finding and conclusion that Petitioner is entitled to any amount

recovered by Respondents from Petitioner pursuant to the decisions and determinations in

the Decision Letters, plus 8% interest on any money received from Petitioner as provided

by law, together with Petitioner's attorneys' fees as provided by law for the reasons set

forth above; and

C. Such other and further relief as the Commission deems appropriate under

the circumstances.

15 JEF-263428-3

JEF-263428-3

Respectfully submitted,

HUSCH BLACKWELL LLP

By:~ HAR M.TETTLEBAmr- #20005

16

EMILY M. PARK #65089 235 East High Street, Suite 200 Post Office Box 1251 Jefferson City, Missouri 65102 Phone: (573) 635-9118 Fax: (573) 634-7854 [email protected] [email protected] [email protected]

ATTORNEYS FOR PETITIONER

''-""'

. ~:.:

Yit-1issouri D-:pt1rtrne11t· of i SOCIAL SERVICE

lour Pote11ti.t-d. Our ~ ... up-port JE IAH W. (JAY) NIXON, GOVERNOR • BRIAN KINKADE, ACTING DIRECTOR

Maxim Healthcare Services, Inc. 11330 Olive Blvd, Ste 200 St. Louis, MO 63141 .

Dear Maxim Healthcare Services, Inc.:

April 15, 014

MISSOURI MEDICAID AUDIT & COMPLIANCE UNIT

r•.o. RO\ 1,5''!!) • .H H E~N">'< en,. \J() <i:'1!1'.:-i>:'t,1 W\\ 'r\·.OSS.1\10,\;fJ\' • :'-73-751-.~.\'l'l

VIA CERTIFIED MAIL 7012 3460 0000 4431 4616

Provider NP! #1346416492

Pursuant to the responsibility, as set fo h in Title 42 of the Code of Federal Regulation (CFR) Parts 456.1 through 456.23, Mis~ouri M dicaid Audit and Compliance ("MMAC"), Provider Review, has conducted a post-payment review o your MO HealthNet claims.

This review has identified billing errors in the amount of $64,909.75, as detailed in the enclosed documents: ,

I • Attachment A - Outline of incorrect bil)ing procedures (errors identified);

• Attachment B - A listing of MO Hea!thNet eligible participants for whom claims were submitted. The claims reviewed ar~ identified. The information listed includes the participant's name, I.D. number, date: of service, date paid, amount paid, amount of the overpayment, and error/no error (indicated by an alpha character). All claims not identified as reviewed may be subjectto future post-payment reviews.

The attachments, together with this lett~r, are your official notice of the claims incorrectly submitted and the total overpayment resultin1 from these errors. If you do not intend to appeal this decision, a written plan of co ective action addressing how the identified billing errors will be corrected in the future (signed and dated by the enrolled provider) must be sent to MMAC within ten days of receipt f this notice; please send this information to my attention at the above address.

Because the amount due is in excess of $1000, you may, within ten days of receipt of this notice, submit a repayment plan for 40 percent of the overpayment amount to MMAC for approval.

In accordance with State Regulation 13 CSR 70-3.030 (6), no repayment plans will be considered for the first 60 percent of the overpayment amount. The first 60 percent is to be repaid within 45 days of receipt of this notice should you elect: to make repayment directly to MMAC. You will be notified within ten days of MMAC's recei~ of such a repayment plan whether it is rejected,

I

accepted, or if a modified version could be acceprble.

If you wish to request that repayme t of the $64,909.75 be accomplished through withholding from current reimbursement, as is generally preferred by MMAC, please notify

RELAY MISSOURI

FOR HEARING 1"D SPEECH IMPAIRED

1-800-735-2466 VOICE • 1-g00-735-2966 TEXT .PHONE

An Equal Opporl1111ity limplnyer, ·=rce.• provided un a nn11di.<crimlna1ory ha.sis.

EXIIlBIT A

Maxim Healthcare Services, Inc. Personal Care Provider

Page 2 t,·

this office in writing within ten days of re ipt of this notice. Do not submit on-line adjustments for those claims identified s errors. Doing this could cause adverse consequences such as duplicate recouprent or unnecessary claim voids. If an adjustment is needed by your organization,! a representative from MMAC will contact you with specific instructions. ·

You will be promptly notified if such repayment through withholding is not acceptable to MMAC. If acceptable, MMAC will then determine the actual amounts to be withheld in order to recover the overpayment amount.

If the overpayment is not either repaid in full or an agreement reached whereby repayment will be made through withholding amounts fro;· current reimbursement at the expiration of 45 days from receipt of this letter, MMAC will ta e immediate action to recover the overpayment amount. If a repayment plan has been agree upon for 40 percent of the total overpayment, MMAC will only take action to recover 60 perce~t. Such recovery action may include withholding from your current MO HealthNet reimbursement, as authorized by State Regulation 13 CSR 70-3.030 (6).

This is a final decision regarding administration of the medical assistance program in Missouri. Missouri Statute, Section 208.156, RSMo (2000) provides for appeal of this decision.

If you were adversely affected by this decision, you may appeal this decision to the Administrative Hearing Commission. To appeal, you must file a petition with the Administrative Hearing Commission within 30 days from the date of mailing or delivery of this decision, whichever is earlier; except that claims of less than $500 may be accumulated until such claims total that sum and, at which time, you have 90 days to file the petition. If any such petition is sent by registered mail or certified mail, the petition will be deemed filed on the date it is mailed. If any such petition is sent by any method other than registered mail or certified mail, it will be deemed flied on the date it is received by the Commissiqn. Appealing this decision can only be made to the Administrative Hearing Commission and not to MMAC or MHD.

Compliance with this decision does not absolve the provider, or any other person or entity, from any criminal penalty or civil liability that may arise from any action that may be brought by any federal agency, other state agency, or prosecutor. The Missouri Department of Social Services, Missouri Medicaid Audit and Compliance Unit, has no authority to bind or restrict in any way the actions of other state agencies or offices, federal agencies or offices, or prosecutors.

If you have any questions concerning this review, please direct them to this office at (573) 751-3399.

Sincerely, .

~l~<;::~ Tracy Sigg Provider Review Analyst

Enclosure

The Missouri Medicaid Audit and Compliance Unit ("MMAC") is the unit within the Department of Social Services ("DSS"), the single state agency responsible for the administration of the Medicaid Title XIX Program in Missouri, charged with administering and managing Medicaid Title XIX audit and compliance initiatives and provider contracts under the Medicaid Title XIX Program. One of MMAC's responsibilities, as directed by the DSS, is to perform the functions and operations formerly under the MO HealthNet Division ("MHD"), Program Integrity Unit which includes monitoring the utilization of MHD services in the State in accordance with any and all applicable federal and state laws and regulatio'"'5.

I

ATTACHMENT 'A' Maxim Healthcare Services, Inc Page 1 of 2

ATTACHMENT B- Outline of Incorrect Billing Procedures

The following errors have been identified during a recent review of your post-paid claims. Some of the errors may have caused incorrect payment due to billing or documentation errors. Each alpha character, below, correlates with the specified claims noted on Attachment 'B' and indicates the error and sites the program policy supporting the error.

As a MO HealthNet provider, you agreed to comply with the policies and procedures as required by Mo HealthNet (the Medicaid administrator in Missouri) and the United States Department of Health and Human Services in the delivery of services and merchandise and in submitting claims for payment.

ERRORS

A. The provider billed for more units than are documented on the time sheet.

A unit of service is defined in 13 CSR 70-91.010 (4)(A) 1. as fifteen minutes.

In violation 13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency

against a provider for any one of the following reasons:

4. Services billed to MO HealthNet that are not adequately documented in the

patient's medical records shall be considered a violation of this section.

(This error did result in an overpayment and is marked as error 'A' on attachment B)

B. There is no daily participant's signature on the time sheet.

Refer to 13 CSR 7D-91.010 {4)(A) 2. F., documentation of services delivered by the provider must

include, for each date of service, the signature of the recipient; or the mark of the recipient

witnessed by at least one person, or the signature of another responsible person present in the

recipient's home at the time of the service. A responsible person may include the personal care

aide's supervisor, if the supervisor is present in the home at the time of service delivery. The

personal care aide may only sign on behalf of the recipient when the recipient is unable to sign

and there is no other responsible person present.

Section 13.7.D(l) 6. of the MO HealthNet Provider Manual on Personal Care, incorporated into

regulation by reference at 13 CSR 70-3.030 (1), continues: The entire signature of the

participant or witness to the mark or the responsible party must be present in the record for

each date of service billed to MO HealthNet. Initials are not acceptable in lieu of the entire

signature.

ATTACHMENT 'A' Maxim Healthcare Services, Inc. Page2 of2

13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency against a

provider for any one of the following reasons:

7. Breaching of the terms of the MO HealthNet provider agreement of

any current written and published policies and procedures of the MO

HealthNet program (Such policies and procedures are contained in

provider manuals or bulletins which are incorporated by reference and

made a part of this rule as published by the Department of Social

Services, MO HealthNet Division, 615 Howerton Court, Jefferson City,

MO 65109, at its website www.dss.mo.gov/mhd, September 15, 2009.

(This error did result in an overpayment and is marked as error 'B' on attachment B}

C. There is no documentation of services provided on this date.

Refer to 13 CSR 70-3.030 (2)(A) adequate documentation means documentation from which

services rendered can be readily discerned and verified with reasonable certainty. Section

13.7.C of the MO HealthNet Provider Manual on Personal Care states all services provided must

be adequately documented in the medical record.



4. Services billed to MO HealthNet that are not adequately documented

in the patient's medical records or for which there is no record that

services were performed shall be considered a violation of this section.





made part of this rule as published by the Department of Social



This rule does not incorporate any subsequent amendments or

additions.)

(This error did result in an pverpayment and is marked as error 'C' on attachment B)

MO HealthNet Manuals, Bul/etins1 sample forms, and the MO HealthNet Forms Request document are

available via the Internet at the MO HealthNet Division's website: www.dssstate.mo.us/mhd.

,,, I

r S~CLtl'SER11cEs lour Potential. Our Support.

JERE!MIAH \V, (JAY) NIXON, GOVERNOR • BRIAN KINKADE, ACTING DIRECTOR

April 15, 2014

MISSOURI MEDICAID AUDIT & COMPLIANCE UNIT

r.o.11n~ (1.'i01) • .11:wrnsoN (Tn. "o 65102-1,5110 ww,\',OSS.~J!I.GO\' • :iiJ-751-.UIJ<)

Maxim Healthcare Services, Inc. 11330 Olive Blvd, Ste 200

VIA CERTIFIED MAIL 7012 3460 0000 4431 4616

St. Louis, MO 63141 Provider NPI #1437325586

Dear Maxim Healthcare Services, Inc.:

Pursuant to the responsibility, as set forth in Title 42 of the Code of Federal Regulation (CFR) Parts 456.1 through 456.23, Missouri Medicaid Audit and Compliance ("MMAC"), Provider Review, has conducted a post-payment review of your MO HealthNet claims.

This review has identified billing errors In the amount of $9,178.62, as detailed in the enclosed documents:

• Attachment A - Outline of Incorrect billing procedures (errors Identified);

• Attachment B - A listing of MO HealthNet eligible participants for whom claims were submitted. The claims reviewed are Identified. The information listed includes the participant's name, I.D. number, date of service, date paid, amount paid, amount of the overpayment, and error/no error (indicated by an alpha character). All claims not identified as reviewed may be subject to future post-payment reviews.

The attachments, together with this letter, are your official notice of the claims incorrectly submitted and the total overpayment resulting from these errors. If you do not intend to appeal this decision, a written plan of corrective action addressing how the identified billing errors will be corrected in the future (signed and dated by the enrolled ·provider) must be sent to MMAC within ten days of receipt of this notice; please send this Information to my attention at the above address.

Because the amount due is In excess of $1000, you may, within ten days of receipt of this notice, submit a repayment plan for 40 percent of the overpayment amount to MMAC for approval.

In accordance with State Regulation 13 CSR 70-3.030 (6), no repayment plans will be considered for the first 60 percent of the overpayment amount. The first 60 percent Is to be repaid within 45 days of receipt of this notice should you elect to make repayment directly to MMAC. You will be notified within ten days of MMAC's receipt of such a repayment plan whether it is rejected, accepted, or if a modified version could be acceptable.

If you wish to request that repayment of the $9,178.62 be accomplished through withholding from current reimbursement, as is generally preferred by MMAC, please notify

RELAY MISSOURI

FOR HEARING AND SPEECH IMPAIRED

t:so0-735-2466 VOICE • l-800-735-2966 TEXT PHONE An Equal Opportl111it;• Emplo:,er. .<errlces providl!ll on a 11ondi.<eriD1i11{lfo1J• ha,ri.s.

EXIIlBITB

Maxim Healthcare Services, Inc. Homemaker Chore Provider Page 2

this office in writing within ten days of receipt of this notice. Do not submit on-line adjustments for those claims identified · as errors. Doing this could cause adverse consequences such as duplicate recoupment or unnecessary claim voids. If an adjustment is needed by your organization, a representative from MMAC will contact you with specific instructions.

You will be promptly notified If such repayment through withholding is not acceptable to MMAC. If acceptable, MMAC wirl then determine the actual amounts to be withheld In order to recover the overpayment amount.

If the overpayment Is not either repaid in full or an agreement reached whereby repayment will be made through withholding amounts from current reimbursement at the expiration of 45 days from receipt of this letter, MMAC will take Immediate action to recover the overpayment amount. If a repayment plan has been agreed upon for 40 percent of. the total overpayment, MMAC will only take action to recover 60 percent. Such recovery action may include withholding from your current MO HealthNet reimbursement, as authorized by State Regulation 13 CSR 70-3.030 (6).

This is a final decision regarding administration of the medical assistance program In Missouri. Missouri Statute, Section 208.156, RSMo (2000) provides for appeal of this decision.

If you were adversely affected by this decision, you may appeal this decision to the Administrative Hearing Commission. To appeal, you must file a petition with the Administrative Hearing Commission within 30 days from the date of malling or delivery of this decision, whichever is earlier; except that claims of less than $500 may be accumulated until such claims total that ·sum and, at which time, you have 90 days to file the petition. If any such petition is sent by registered mail or certified mall, the petition will be deemed filed on the date it is mailed. If any such petition Is sent by any method other than registered mail or certified mail, It will be deemed filed on the date it is received by the Commission. Appealing this decision can only be made to the Administrative Hearing Commission and not to MMAC or MHD.

Compliance with this decision does not absolve the provider, or any other person or entity, from any criminal penalty or civil liability that may arise from any action that may be brought by any federal agency, other state agency, or prosecutor. The Missouri Department of Social Services, Missouri Medicaid Audit and Compliance Unit, has no authority to bind or restrict in any way the actions of other state agencies or offices, federal agencies .or offices, or prosecutors.

If you have any questions concerning this review, please direct them to this office at (573) 751-3399.

Sincerely, ~---·----2

// l<-..:~~

Tracy Sigr . Provider Review Analyst

Enclosure

The Missouri Medicaid Audit and Compliance Unit ("MMAC") is the unit within the Department of Social Services ("DSS"), the single state agency responsible for the administration of the Medicaid Title XIX Program in Missouri, charged with administering and managing Medicaid Title XIX audit and compliance initiatives and provider contracts under the Medicaid Title XIX Program. One of MMAC's responsibilities, as directed by the DSS, is to perform the functions and operations formerly under the MO HealthNet DIVision ("MHD"), Program Integrity Unit which includes monitoring the utilization of MHD services in the State In accordance with any and all applicable federal and state laws and regulations.

ATTACHMENT 'A' Maxim Healthcare Services, Inc Page 1 of2

ATTACHMENT B - Outline of Incorrect Billing Procedures

The following errors have been Identified during a recent review of your post-paid claims. Some of the errors may have caused Incorrect payment due to billing ·or documentation errors. Each alpha character, below, correlates with the specified claims noted on Attachment 'B' and indicates the error and sites the program policy supporting the error.

As a MO HealthNet provider, you agreed to comply with the policies and procedures as required by Mo HealthNet (the Medicaid administrator In Missouri) and the United States Department of Health and Human Services In the delivery of services and merchandise and In submitting claims for payment.

ERRORS

A. The provider billed for more units than are documented on the time sheet.

A unit of service is defined in 13 CSR 70-91.010 (4)(A) 1. as fifteen minutes.



4. Services billed to MO HealthNet that are not adequately documented in the

patient's medical records shall be considered a violation of this section.

(This error did result in an overpayment and is marked as error 'A' on attachment B)

B. There Is no daily participant's signature on the time sheet.

Refer to 13 CSR 70-91.010 (4)(A) 2. F., documentation of services delivered by the provider must

include, for each date of service, the signature of the recipient, or the mark of the recipient

witnessed by at least one person, or the signature of another responsible person present in the

recipient's home at the time of the service. A responsible person may include the personal care

aide's supervisor, if the supervisor is present in the home at the time of service delivery. The

personal care aide may only sign on behalf of the recipient when the recipient is unable to sign

and there is no other responsible person present.

Section 13.7.0(1) 6. of the MO HealthNet Provider Manual on Personal Care, incorporated into

regulation by reference at 13 CSR 70-3.030 (1), continues: The entire signature of the

participant or witness to the mark or the responsible party must be present in the record for

each date of service billed to MO Hea(thNet. Initials are not acceptable in lieu of the entire

signature.

ATTACHMENT 'A' Maxim Healthcare Services, Inc. Page2 of2

13 CSR 70-3.030 (3)(A) allows sanctions to be imposed by the MO HealthNet agency against a

provider for any one of the following reasons:



HealthNet program (Such policies and procedures are contained In


made a part of this rule as published by the Department of Social


MO 65109, at its website www.dss.mo.gov/mhd. September 15, 2009.

(This error did result in an overpayment and is marked as error 'B' on attachment B)

c. There is no documentation of services provided on this date.

Refer to 13 CSR 70-3.030 (2)(A) adequate documentation means documentation from which

services rendered can be readily discerned and verified with reasonable certainty. Section

13.7.C of the MO HealthNet Provider Manual on Personal Care states all services provided must

be adequately documented in the medical record.



4. Services billed to MO HealthNet that are not adequately documented

in the patient's medical records or for which there is no record that

services were performed shall be considered a violation of this section.





made part of this rule as published by the Department of Social



This rule does not incorporate any subsequent amendments or

additions.)

(This error did result in an overpayment and is marked as error 'C! on attachment B)

MO Health Net Manuals, Bulletins, sampfe forms, and the MO Health Net Forms Request document are available via the Internet at the MD Health Net Dlvisfon 's website: www.dss.state.mo.us/mhd.

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