MEDICAID RECOVERY AUDIT CONTRACTORS

Transcription

1 MEDICAID RECOVERY AUDIT CONTRACTORS TENNESSEE EXPERIENCE PRESENTERS Andrea M. Fitzgerald, CHC East Region Lead and Tennessee Compliance Officer UnitedHealthcare Community Plan Brentwood, TN Michael A. Wynne, CCEP BlueCare Tennessee Compliance Officer BlueCross Blue Shield of Tennessee Chattanooga, TN 1

2 TENNCARE On January 1, 1994, Tennessee made history by withdrawing from the Federal Medicaid program and implementing an innovative new health care reform plan called TennCare, which extended health coverage not only to the Medicaid population, but also to people who are uninsured or uninsurable, using a system of managed care. TENNCARE TennCare covers approximately 1.3 million Tennesseans Medical, behavioral and long-term care services are integrated and covered by "at risk" MCOs Current MCOs Amerigroup BlueCross Blue Shield of Tennessee UnitedHealthcare Community Plan 2

3 TENNCARE Carve-outs: Pharmacy Benefits Manager for coverage of prescription drugs and a Dental Benefits Manager for provision of dental services to children under age 21. TENNCARE RAC 3

4 CMS RULE BASIS FOR IMPLEMENTATION On September 16, 2011, CMS published the final rule implementing Section 6411 of the Patient Protection and Affordable Care Act Required States to implement Medicaid Recovery Audit Contractor (RAC) programs by January 1, 2012 CMS RULE BASIS FOR IMPLEMENTATION CMS Rule clarified that fee for service Medicaid Agencies must implement a RAC by January 1, 2012 Under the final rule, States may include Medicaid managed care claims for review by RACs Tennessee chose to implement 4

5 TENNCARE MODEL 100% Medicaid Managed Care MCOs have an audit and recovery process HMS is currently the TennCare RAC HMS is also a subcontractor of all 3 MCOs Final Rule allowed a 3 year look-back TennCare requested and was granted 5 years RAC TAGGING Standard/Matter/Claim Tags Multiple entities can tag a Matter Claim Tags are approved/ disapproved within 30 days Tags have pre-defined lifespans Must continue to be worked 5

6 IMPLEMENTATION POSITIVES MCOs were consulted in development phase RAC recovery after 180 days now 365 Tagging database receptive to input on data layout Feedback taken into consideration when RAC policy was developed IMPLEMENTATION POSITIVES TennCare did not rush the implementation Fully insured claims (nursing homes/long term care) Data is shared with MCOs RAC identified schemes 6

7 IMPLEMENTATION CHALLENGES Reporting tagging process/template continues to evolve Expectations realigned with growing experience RAC calculating over/under payments a challenge MCOs contract independently with providers IMPLEMENTATION CHALLENGES RAC mining state s encounter data May or may not match MCO encounter file Provider returning overpayments after RAC inquiry Could come to MCO as unsolicited overpayment or corrected claim Arbitration agency TennCare 7

8 MCO - IMPACT MCOs have on-going recovery operations Provider Abrasion Confusion when contacted by another entity relating to overpayments Recoveries by RAC are kept by TennCare Encounter adjustments RAC VS. FWA INVESTIGATIONS Change from prior method of handling potential FWA referrals New entities were now designated repository for and manager of referral information and subsequent actions Prolonged dialogue regarding the dividing lines between Fraud, Waste and Abuse Order of importance modified Different players with different objectives 8

9 TIPS FOR COMPLIANCE PROFESSIONALS Approach the opportunity with a collaborative spirit Engage early and often Share best practices from your current processes Letter generation, call volume, etc. Understand that the existing methods will change Be flexible with reporting expectations Prepare to accommodate changing reporting and program needs QUESTIONS? 9