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State of Washington Medicaid -

Recovery Audit Contractor (RAC)

November 9, 2012

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Agenda

• Introductions

• Implementation Timeline

• Medicaid RAC Operations

• Provider Assistance and Online Tools

• Customer Service

• Washington HCA RAC Online Portal

• Contact Information

• Provider Feedback

• Open Question and Answer

Biographical Information

•Martin Thies, Ph.D., C.I.A.

•Currently the Manager of the Office of Program

Integrity, Washington State Health Care Authority,

and the contract manager for the Washington State

RAC

•Certified Internal Auditor, formerly

•Senior Auditor for the Department of Social and

Health Services

•Chief Compliance Officer for the Washington State

Mental Health

•Chief of Quality Assurance for Washington State

Economic Services Administration

•Program Integrity Manager, Washington State EHR

Incentive Program

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Biographical Information

•Keith Livingston, Project Director

•More than 20 years of experience managing

complex projects, systems, and personnel

•Managed the implementation of CGI’s

Customize Audit System for clients licensing

the enterprise‐wide claims audit and fraud

detection system to identify improper

payments for the past 10 years

•Served in multiple management and

supervisory roles for Regence BlueShield in

Washington for 10 years, overseeing claims

processors and customer service

representatives, the transition and conversion

of paper claims and correspondence data to

electronic format, and the implementation of a

new claims auditing system, increasing

improper payment recoveries

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Implementation Timeline

CMS Recovery Audit Contractor Final Rule

• CMS published the Final Rule expanding the federal Recovery Audit Contractor program to state Medicaid agencies on September 16, 2011. These regulations were effective starting January 1, 2012.

• 42 CFR Part 455

• The State of Washington Medicaid RAC Contract was signed in May, 2012. CGI will conduct audits and support the work of Health Care Authority staff in compliance with the Final Rule regulations.

Implementation Timeline

• Projected Implementation Timeline • July 2012:

• Developed the Provider website

• Call Center configuration and programming initiated

• August 2012: • Washington HCA review and coordination with CGI Federal on review

focus areas

• September 2012: • Activated call center

• Implemented Washington RAC Provider website

• October 2012 • Performed Initial Provider Outreach Session

• November 2012 • Perform Additional Provider Outreach Sessions

• Initiate Medical Record requests

Medicaid RAC Operations

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Medicaid RAC Operations

As the Recovery Audit Contractor for Washington Medicaid, CGI Federal has established:

• Provider Education and Outreach program

• Customer Service Call Center for providers, with a toll-free telephone number 1-855-210-3438, Option 4

• Call Center hours between 8:00am – 4:30pm PST

• Washington Web-based Portal for HCA Providers at: http://wahca.cgicleve.com

• Provider Address and Contact Maintenance: CGI will compile and maintain provider-approved mailing addresses and points of contact

Provider Address Information

• CGI references the State of Washington HCA’s

ProviderOne database information to identify

provider address and contact information

• For ProviderOne address updates:

• Providers must call ProviderOne at 1-800-562-3022

• Follow the prompts as directed to update the provider address and contact information

• A fact sheet on this update process may be found at: http://hrsa.dshs.wa.gov/providerone/Providers/Fact%20Sheets/P1PR016.pdf

• Additional ProviderOne update information may be found at: http://hrsa.dshs.wa.gov/providerone/providers.htm

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Provider Address Maintenance

• CGI’s Washington HCA Medicaid RAC Web Portal address maintenance function enables a provider to update the following audit contact information: mailing address, billing address, contact name and phone and fax numbers

• Mailing Address impacts Medical Records Request Letters

• Billing Address impacts Findings Letters

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Medical Records Submission

• Medical Record submission standards are available on

CGI’s Washington HCA Medicaid RAC Web Portal

• Providers may submit medical records in the following formats:

• Electronic upload via the Washington Provider Portal

• CD/DVD

• Paper format

• Fax

• Per the WAC 182-502A-0800, CGI will not reimburse copying fees or administrative fees associated with providing records requested for review

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CGI Staff

• CGI employs physicians who will assist with the medical necessity determinations

• The CGI audit staff is comprised of both registered nurses and certified professional medical coding specialists

•The audit staff have experience with various audit types, including:

• Medical Necessity determinations

•Charge review

•DRG

•Coding validation

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Types of Reviews

•CGI will follow the Washington HCA Provider Audits and Appeals guidelines referenced in Washington Administrative Codes (WAC) 182-802A and WAC 182-502-0230

•The Medicaid RAC process is specific to Washington’s Recovery Audit Contractor program. HCA has no plans to release a specific Statement of Work regarding the Medicaid Recovery Audit Contractor program

•CGI audits currently:

•Will not include Healthy Options member claims

•Will only address inpatient claims

•Will not include DRG validations

•If an Emergency Department visit is part of an Inpatient stay, the Emergency Department portion of the stay would be included in the inpatient audit

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Complex Reviews

Complex reviews look at claim information and include medical necessity determinations. These may be performed as a desk audit, onsite audit, or a combination of the two processes. These reviews require medical record or other documentation to complete the review.

Desk Audits

• Providers will receive a request letter to submit copies of medical records to CGI’s Cleveland office

Onsite Audits

• A notification letter will be sent by CGI to the provider prior to the on-site visit listing the date and time of the audit

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Chart Review Details

• HCA will assess the selected areas for review by CGI

• Review areas may include the following:

• Services provided must be included as a covered service, as described in Washington Administrative Code (WAC) 182-550-1400 and 182-550-1500

• Services must be medically necessary, as defined in WAC 182-550-1700 and provided at the appropriate level of care

• Services provided must be documented in the medical record and billed as provided

• Coding Determinations

• Determinations are made following national standards for coding guidelines, such as American Hospital Association’s (AHA) Coding Clinics

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Provider Notifications

• CGI will issue the following letters according to the program

timelines:

• Medical Record Request Letter

• Providers have 30 days to submit requested documents

• Preliminary Review Results Notice

• CGI will send within 60 days of receiving all documents

• Informal Dispute Response

• CGI will send a single response letter for all claims disputed

• Final Review Results/Overpayment Demand Notice

• CGI will send within:

• 45 days of Preliminary Review Results notification

• 60 days of completing Informal Dispute Reviews

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Exit Conference

A provider may request an exit conference where CGI will provide summary level review findings

When reviews are performed at the providers location the exit conference will be held on the final day of the audit

For reviews performed at the CGI office, exit conferences may be requested prior to the preliminary findings notice submission

Providers may request an exit conference by completing and submitting an exit conference request form

The exit conference request form is located on the Washington HCA RAC Online Portal Contact page at the following address http://wahca.cgicleve.com

Audit Procedures and Timelines

Audit Look-Back Period:

• CGI audits will utilize a three year look-back period

Record Request Volumes:

• At this time, CGI and HCA are coordinating efforts to take into consideration the number of record requests per audit

Record Request Frequency:

• The audit request frequency will depend on the overall identified claim volume for a provider

• CGI and HCA will work with the providers to minimize provider disruption

Audit Procedures and Timelines

• Audit Notification: The provider is notified of an audit a minimum of 30 calendar days before the review begins

• Providers will send in records within 30 calendar days for desk audits

• CGI will schedule dates, 30 days in advance, for on-site reviews at the provider’s location

• Audit Completion: Per Code of Federal Regulations, CGI has 60 calendar days to complete the review process including these key activities:

• CGI review of submitted records

• HCA staff have access to the review findings

• CGI holds an exit conference with the Provider

• The preliminary review results are sent to the Provider

Audit Reports

Preliminary Review Results Notice:

• HCA will review and approve the preliminary review results notice prior to being sent to providers

• Once approved, preliminary review results notices will be sent to the provider by certified mail

• All review findings will be included in a single letter

• HCA will also receive a copy of the preliminary review notice

Final Review Results Notice:

• HCA will review and approve the final review results notice prior to being sent to providers

• Once approved, the final review results notice will be sent by certified mail with a copy to HCA

• Submitted after the preliminary review response time has expired or the dispute process is completed

• This notice will contain the final overpayment amount and directives, including information regarding filing an appeal

Audit Dispute Procedures and Timelines

Providers have two opportunities to dispute audit findings:

• Informal Disputes will follow the steps outlined in WAC 182-502A-1100

• CGI is responsible for the Informal Dispute reviews. Providers may submit additional information as an informal dispute within 30 calendar days of receipt of their Preliminary Review Results Notice

• CGI notifies the Provider of the outcome in a single letter for all claims involved in the audit

• Appeals will follow the steps outlined in WAC 182-502A-1200

• Providers may request a Formal Appeal within 28 calendar days of the provider’s receipt of the Final Review Results/Overpayment Notice

Audit Dispute and Appeal Notification Process

Informal Dispute Mailing Address: CGI Federal Inc.

Attn: Washington RAC, Informal Dispute

1001 Lakeside Avenue, Suite 800

Cleveland, Ohio 44114-1151

• To schedule an informal dispute through CGI, please follow the instructions on the Informal Dispute Request form located at http://wahca.cgicleve.com/ContactInfo.aspx

Administrative Hearings/Appeals Mailing Address: The Office of Financial Recovery

PO Box 9501

712 Pear Street SE

Olympia, WA 98507-9501

Audit Overpayment Adjustments

Adjustment and Demand Information

• Once a Final Review Result is generated, CGI sends results to HCA

• Letters mailed by CGI with Overpayment / Underpayment information

• HCA is developing processes to receive overpayments and code these back to claims data in ProviderOne

Submitting Claims After the Audit

• Providers will be allowed to re-bill for allowable charges after receipt of the Final Review notice

• A re-billed claim must reflect the adjusted claim number, and should be submitted within 60 days for optimal processing

• HCA and the Office of Accounting Services (OAS) process overpayments

• Providers must submit a check to the OAS (this can encompass multiple claims per check) based on the Final Findings documentation

• A copy of the CGI claim overpayment list must be submitted with the check for the OAS to correctly apply the funds received

Provider Assistance and Online Tools

Provider Assistance and Online Tools: Customer Service

• The CGI Call Center Team will be handling the Washington HCA Medicaid RAC provider calls. The Call Center Team has:

• Existing knowledge of CGI systems and processes

• Successfully completed CGI training program on the Washington RAC audit processes

• The CGI Washington HCA Medicaid Call Center hours of operation are between 8:00am and 4:30pm PST

Toll Free: 1-855-210-3438, Option 4

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Provider Assistance and Online Tools: Washington HCA RAC Web Portal

• The Washington HCA RAC Web Portal is available at the following link: http://wahca.cgicleve.com

• Providers can use the web portal to access the following:

• View audit findings

• View audit status

• Update address and contact information

• View Medical Record Submission and Contact information

• View general RAC program information

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Provider Assistance and Online Tools: Washington HCA RAC Web Portal (cont’d)

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• Access to confidential data is managed through a unique

log-in and verification process specific to each provider

• Providers authenticate by clicking on the Provider link and

entering their Provider Number or NPI

Provider Assistance and Online Tools: Washington HCA RAC Web Portal (cont’d)

• Additional information is required such as the Billed Charges or the

Letter ID for a claim under review

• A single administrator may view the status for multiple providers if they

have the required claim level information

Provider Assistance and Online Tools: Washington HCA RAC Web Portal (cont’d)

• A Messaging service is available for communicating important updates to Washington’s provider community

• Once authenticated to the website, click on the Home link to view any messages, which will be displayed at the top of the page

Washington HCA RAC Web Portal: Claim Status

• Providers can view the status of their RAC cases from the Claim Status link shown below

Washington HCA RAC Web Portal: Claim Status Details

• Detailed information on cases is available from the Claim Audit Details link

• Providers may search for claims by the following:

• Status

• Status Date

• Audit Number

• Medical Record Number

Washington HCA RAC Web Portal: Address and Contact Maintenance

• Providers may only update their information for:

• Addresses identified for the logon identity

• Open and view the current information by selecting the link in the ‘Provider Number’ column to open the Address Maintenance

Contact Information

CGI Medicaid RAC Contact Information

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Call Center for CGI Federal Medicaid

RAC Washington HCA

Toll Free: 1-855-210-3438, Option 4

E-mail: rac.medicaid@cgifederal.com

Website: http://wahca.cgicleve.com

Provider Feedback

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• We want to take this opportunity and ask participants to share information with the group in relation to the recovery audit process

• Lessons learned

• Experiences with the Medicare RACs

Questions and Answers

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