Claims Compliance Analysis

Amy Kanter, SBS AuditorMichigan Department of Health and Human Services

2015 SBS Conference – Traverse City, MI

August 17 & 18, 2015

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Background(MI Medicaid Provider Manual)

The Centers for Medicare & Medicaid Services (CMS) require Michigan SBS providers to submit procedure specific fee for service claims for all Medicaid allowable services

These claims do not generate a payment but are required by CMS in order to monitor the services provided, the eligibility of the recipient, and provide an audit trail

If the claim volume decreases significantly or drops to zero in any two consecutive months, all interim payments will be held until the provider is contacted and the issue resolved

MDHHS will monitor provider claim volume to make sure that this mandate is followed

Background cont.(MI Medicaid Provider Manual)

It is the intent of the State of pursue, when necessary, remedial action or implement a Corrective Plan if the ISDs or their vendors are not in compliance with Medicaid policy and procedures. If these actions are not successful, a payment freeze will be implemented and sanctions put in place until the matter is resolved. ISDs are responsible for the actions of their vendors

Historical Trends

Aug-1

3

Sep-1

3

Oct-1

3

Nov-1

3

Dec-1

3

Jan-

14

Feb-1

4

Mar

-14

Apr-1

4

May

-14

Jun-

14

Jul-1

4

Aug-1

4

Sep-1

4

Oct-1

4

Nov-1

4

Dec-1

4

Jan-

15

Feb-1

5

Mar

-15

Apr-1

5

May

-15

Jun-

150

5

10

15

20

25

30

Number of ISD's Below 85%

Number of ISD's Below 85%

Monthly Claims Comparison Process Queries are run to pull the claims Information is compiled into a spreadsheet and a

rolling average is calculated Can track long term trends rather than short term

billing variances Percentages are identified Letters/Information Sheets are issued Response letters are issued for the documentation

provided

Claims Pull Process

Claims are pulled with the following criteriaBy NPI numberPulled by date of serviceClaim type G- School Based ServicesLimited to a paid date of the 18th of each

month

SBS Procedure Codes - Medical

SBS Procedure Codes - Speech

SBS Procedure Codes- Psych

SBS Procedure Codes- Trans

Psych, Speech, & Transportation

Psych has been removed due to prior controversy Speech has been removed due to recent changes in

the licensure Transportation is redundant as there are supposed

to be medical services on the same day and would be counted in the Medical portion

Our goal is to compare the numbers as equally across the ISD’s as possible

Claim Process Steps

Information is input into a spreadsheet Calculate rolling averages Calculate a lag time in claims submissions

to determine an average for a look back period to allow time for claims to be paid after submitted

Calculate percentages

Letters Issued

Letter 1- Warning Letter Letter 2- 30 Day Letter Letter 3- Suspension Letter

In response to all required documentation- a response letter is issued to the ISD

Information sheets are also provided to reflect the trends of the claims

Sample Warning Letter

Sample 30 Day Notice Letter

Sample Payment Suspension Letter

Sample Response Letter

Information Sheet Provided

First page shows the actual claims that were paid by month Graph reflects the rolling averages and trends that may help identify

problems Second portion shows the 12 month rolling average calculated Last section reflects the percentages calculated by dividing the

current 12 month rolling average by the prior 12 month rolling average period

Sample Information Sheet

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Sample Information Sheet Continued

Sample Information Sheet Continued

Required Documentation

Communication is important!! Documentation requires detail the reason for the

drop in claims Documentation required the details on the corrective

measures that will be put in place Documentation requires a date of which the

corrective measure will start taking place and claim volumes should start to rise

Effects of Non-Compliance

Interim payments can be suspended until the 85% level is reached

If an ISD comes into compliance at any time during this process, the process stops and missed monthly payments can be made up if requested in writing

Risks of non-compliance on the part of MDHHS CMS sanctions Possible loss of the program

Reasons Behind Drop In Claims

Parental consent changes CHAMPS edit issues Reduction in staff and students Changes in federally funded employees Changes in who does the billing Other issues specifically within the ISD

** Reasons require specific detailed information

Claim Resolution Steps

Determine if the problem lies within the claim being paid. We can provide assistance to help determine the cause of the denials

Identify where the issues lie and possibly using the information sheet to provide trending information over the years

Conference calls

Proactive Steps – ISD

Staff training and follow up Regular evaluation of the RA to stay on top of

denials and their reason Review the internal processes Know program changes Know procedure code changes Identify claim denials and causes

Questions?

Contact Information –

Email: kantera@michigan.govPhone: 517-373-4522Fax: 517-241-7408

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