HMS additional documentation into PIE and attaches it to the appropriate case. Our clinical auditors review all additional information and work closely with providers during this process to ensure that all information and issues are fully considered. We find that a focus on this phase can significantly minimize subsequent appeals. Following the reconsideration period, HMS will send a TNO/Final Audit Report to providers notifying them of DMA’s intent to recover the improper payment. Providers have the right to request an administrative appeal, consistent with the State’s administrative appeal regulations and timing. After cases pass the appeal response period, HMS generates the required deliverables for recovery or recoupment, consistent with DMA’s approved methodology and recovery of the improper payments. Types of Issues That HMS Can Review for DMA HMS has experience, expertise, and well-developed processes that span the full scope of Medicaid service types and improper payment issues. Exhibit E-25 summarizes by service area the types of audit issues that HMS has developed for other states and might be appropriate for DMA under the RAC contract. Exhibit E-25 of Issues That HMS Can Review for DMA Category Description Examples of HMS Success Appropriate admission Mother/baby duplicates Appropriate admission. This review returns approximately Inpatient coding (i.e., Inpatient/outpatient $50 million each year to one DRG) unbundling state client. Bill audit Balance billing Readmissions. HMS recently overpayments Out-of-state identified more than $67 reimbursement error Financial review/credit million in potentially balance Readmissions and inappropriate readmission transfers Medicare deductible/ errors on behalf of one state. coinsurance errors Never events/HACs Credit balance. In 2010, HMS performed more than 4,000 Duplicate/overlapping Credit Balance Audits payments (multiple (onsite and desk) and types) recovered more than $110 Inpatient million for clients through these audits. Many of the audits were safety net audits where another vendor was onsite at the hospital but missed the overpayment. Transfer issues. HMS has recovered more than $2 million for states related to transfer issues where we reviewed episodes of care with multiple institutional providers to ensure an appropriate payment of transfer rate.
HMS additional documentation into PIE and attaches it to the appropriate case. Our clinical auditors review all additional information and work closely with providers during this process to ensure that all information and issues are fully considered. We find that a focus on this phase can significantly minimize subsequent appeals. Following the reconsideration period, HMS will send a TNO/Final Audit Report to providers notifying them of DMA’s intent to recover the improper payment. Providers have the right to request an administrative appeal, consistent with the State’s administrative appeal regulations and timing. After cases pass the appeal response period, HMS generates the required deliverables for recovery or recoupment, consistent with DMA’s approved methodology and recovery of the improper payments. Types of Issues That HMS Can Review for DMA HMS has experience, expertise, and well-developed processes that span the full scope of Medicaid service types and improper payment issues. Exhibit E-25 summarizes by service area the types of audit issues that HMS has developed for other states and might be appropriate for DMA under the RAC contract. Exhibit E-25 of Issues That HMS Can Review for DMA Category Description Examples of HMS Success Inpatient Appropriate admission Inpatient coding (i.e., DRG) Bill audit Out-of-state reimbursement error Readmissions and transfers Never events/HACs Duplicate/overlapping payments (multiple types) Mother/baby duplicates Inpatient/outpatient unbundling Balance billing overpayments Financial review/credit balance Medicare deductible/ coinsurance errors Appropriate admission. This review returns approximately $50 million each year to one state client. Readmissions. HMS recently identified more than $67 million in potentially inappropriate readmission errors on behalf of one state. Credit balance. In 2010, HMS performed more than 4,000 Credit Balance Audits (onsite and desk) and recovered more than $110 million for clients through these audits. Many of the audits were safety net audits where another vendor was onsite at the hospital but missed the overpayment. Transfer issues. HMS has recovered more than $2 million for states related to transfer issues where we reviewed episodes of care with multiple institutional providers to ensure an appropriate payment of transfer rate.
ScopeOfWork-RAC.docx