Centers for Medicare and Medicaid Services (CMS) Special Open Door Forum on the Medicaid Integrity Program
On July 15, 2009 CMS held a special open door forum via teleconference to provide information regarding the implementation of the Medicaid Integrity Program. While many providers are focused on the Medicare Recovery Audit Contractor ("RAC") program, attention must also be paid to the Medicaid Integrity Program (MIP). MIP will consist of audits similar to those of the RAC program as a continued effort to increase detection, enforcement, and prevention of Medicaid fraud and abuse.
Some of the highlights from the open door forum are listed below. For a transcript of the teleconference, click here. (The transcript will be available for downloading for 30 days beginning on July 24, 2009)
Highlights from the CMS Special Open Door Forum on the Medicaid Integrity Program
- Of the audits currently being conducted by the Medicaid Integrity Audit contractors the distribution of the audits are as follows:
- 44% are of hospitals
- 29% are of long-term care facilities
- 21% are of pharmacies
- 6% are of remaining types of providers
- CMS is working to collect a more comprehensive data set from states and other entities in order to supply providers with more information when providers are asked to compile medical records for auditing.
- CMS will work with states, law enforcement officials, and Medicare RAC contractors to prevent the duplication of audits.
- Medicaid Integrity Contractors (MICs) are expected to follow the generally accepted government auditing standards (GAGAS) when conducting audits.
- The adjudication procedures for contesting audit results will be those of the state in which the audit was conducted.
- The Medicaid Integrity Group (MIG) will try to work with the Medicare RAC program in order to streamline the audit process, but without damaging the integrity of the audits.
- The threshold for how far back the MICs may conduct audits of medical records will mirror that of the state in which the audit is conducted.
- Unlike RACs, MICs are not paid on contingency basis, but on a fee for service basis. However, MICs are eligible for awards or bonuses depending on efficiency and effectiveness.
- The umbrella contracts that are awarded are to serve as a competition among a pool of vendors to identify the contractor that will perform the work under task orders.
- There are three types of MICs: (1) Review of Provider MIC; (2) Audit MICs; (3) Education MICs.
- Review MICs' Task Orders:
- CMS Regions:
- Philadelphia & Atlanta: Thomson Reuters
- Dallas, Denver, and Chicago: AdvanceMed
- San Francisco & Seattle: To be awarded by September 2009
- Boston & New York: To be awarded by August 2009
- Audit MICS' Task Orders:
- CMS Regions:
- Philadelphia & Atlanta: Booz Allen Hamilton
- Dallas & Denver: HMS
- San Francisco & Seattle: HMS
- Boston & New York: To be awarded before August 2009
- Chicago & Kansas City: To be awarded in September 2009
- Education umbrella contracts were awarded to Information Experts and Strategic Health Solutions.
- As of date no Education Task Orders have been awarded.
- There will be a nationwide presence of the MICs by September 2009.
- The two major task orders for Education MICs will be:
- Analyze the education and training process for providers.
- Develop web-based training for education efforts.
- CMS excepts Audit MICs to be flexible with the timeframes in which providers are expected to produce medical records that are either offsite or older.
- CMS indicated that large group practices or hospitals may identify a preferred point of contact for receiving any mail with regards to audits (i.e. notification letters).
- When auditing a claim, the criteria or standard will be that which was relevant at the time of the date of service.
- the Medicaid Integrity Group is the process of publishing various documents that will serve as resources for the Medicaid Integrity Program:
- FAQs
- Procurement Timeline for contractors
- The Medicaid Integrity Program's goals and background
- "Audits A-Z"
- Click here to visit the CMS Medicaid Integrity Program Website
