Planning for the inevitable is smart. And it is inevitable if you are a provider and you accept Medicaid that you will undergo some sort of review, whether it is onsite or database checks, in the near future. And only two outcomes can result from this upcoming review:

Are YOU ready for that test???

So, it is imperative to arm yourself with knowledge of your rights, a liability insurance policy that covers attorneys’ fees (and lets you pick your attorney), and confidence that your billing practices comply with rules and regulations.  If you do not know whether your billing practices comply, do a self-audit or hire a knowledgeable billing expert to audit you.

Read or not here they come…

Beginning June 9, 2014, Public Consulting Group (PCG) began scheduling post-enrollment site visits to fulfill federal regulations 42 CFR 455.410 and 455.450, which require all participating providers to be screened according to their categorical risk level: high, moderate, or limited.

What does being high, moderate, or limited risk mean?

If you are limited risk, the state will check your licenses, ensure that you, as a provider, meet criteria for applicable federal and state statutes, conduct license verifications, and conduct database checks on a pre- and post-enrollment basis to ensure that providers continue to meet the enrollment criteria for their provider type.  This is the only category that does not need an onsite review.

If you are moderate risk, the state does everything for you as if you are a limited risk plus perform on-site reviews.  (Enter PCG).

If you are high risk, the state will perform all reviews as if you are a moderate risk but also will conduct a criminal background check, and require the submission of a set of fingerprints in accordance with §455.434. (And you thought fingerprints for only for the accused.)

Let’s discuss in which level risk you fall.  NC Gen. Stat §108C-3 spells out the risk levels.  Are you a new personal care service (PCS) provider getting ready to start your own business?  You are high risk.  Are you a directly-enrolled behavioral health care provider rendering outpatient behavioral health care services?  You are high risk.  Do you provide HIV Management services?  You are high risk.

Here is a list of high risk providers:

• Prospective (newly enrolling) adult care homes delivering Medicaid-reimbursed services.
• Agencies providing behavioral health services, excluding Critical Access Behavioral Health Agencies
• Directly enrolled outpatient behavioral health services providers.
• Prospective (newly enrolling) agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics.
• Agencies providing HIV case management.
• Prospective (newly enrolling) agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).
• Prospective (newly enrolling) agencies providing personal care services or in-home care services.
• Prospective (newly enrolling) agencies providing private duty nursing, home health, or home infusion.
• Providers against whom the Department has imposed a payment suspension based upon a credible allegation of fraud in accordance with 42 C.F.R. § 455.23 within the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the cessation of the payment suspension.
• Providers that were excluded, or whose owners, operators, or managing employees were excluded, by the U.S. Department of Health and Human Services Office of Inspector General or another state’s Medicaid program within the previous 10 years.
• Providers who have incurred a Medicaid or Health Choice final overpayment, assessment, or fine to the Department in excess of twenty percent (20%) of the provider’s payments received from Medicaid and Health Choice in the previous 12-month period. The Department shall return the provider to its original risk category not later than 12 months after the completion of the provider’s repayment of the final overpayment, assessment, or fine.
• Providers whose owners, operators, or managing employees were convicted of a disqualifying offense pursuant to G.S. 108C-4 but were granted an exemption by the Department within the previous 10 years.

Here is a list of moderate risk providers:

•  Ambulance services.
• Comprehensive outpatient rehabilitation facilities
• Critical Access Behavioral Health Agencies.
• Hospice organizations
• Independent clinical laboratories.
• Independent diagnostic testing facilities.
• Pharmacy Services.
• Physical therapists enrolling as individuals or as group practices.
• Revalidating adult care homes delivering Medicaid-reimbursed services.
• Revalidating agencies providing durable medical equipment, including, but not limited to, orthotics and prosthetics
• Revalidating agencies providing home or community-based services pursuant to waivers authorized by the federal Centers for Medicare and Medicaid Services under 42 U.S.C. § 1396n(c).
• Revalidating agencies providing private duty nursing, home health, personal care services or in-home care services, or home infusion.
• Nonemergency medical transportation.

Here are the limited risk providers:

• Ambulatory surgical centers.
• End-stage renal disease facilities.
• Federally qualified health centers.
• Health programs operated by an Indian Health Program (as defined in section 4(12) of the Indian Health Care Improvement Act) or an urban Indian organization (as defined in section 4(29) of the Indian Health Care Improvement Act) that receives funding from the Indian Health Service pursuant to Title V of the Indian Health Care Improvement Act.
• Histocompatibility laboratories.
• Hospitals, including critical access hospitals, Department of Veterans Affairs Hospitals, and other State or federally owned hospital facilities
• Local Education Agencies.
• Mammography screening centers.
• Mass immunization roster billers.
• Nursing facilities, including Intermediate Care Facilities for the Mentally Retarded.
• Organ procurement organizations.
• Physician or nonphysician practitioners (including nurse practitioners, CRNAs, physician assistants, physician extenders, occupational therapists, speech/language pathologists, chiropractors, and audiologists), optometrists, dentists and orthodontists, and medical groups

According to the June 2014 Medicaid Bulletin, the onsite reviews will last approximately two hours and PCG will send 2 representatives to conduct the review.

How to prepare for the onSite reviews

1. Read and learn. (or re-learn, whichever the case may be).

“Providers will be expected to demonstrate a working knowledge of N.C. Medicaid through responses to a series of questions.”  See June 2014 Medicaid Bulletin.

Knowledge is power.  Brush up on your applicable DMA Clinical Coverage Policy.  Review the NC Medicaid Billing Guide.  Re-read your provider participation agreement.  If you don’t understand a section, go to your attorney and ask for an explanation.  Actually read the pertinent federal and state statutes quoted in your participation agreements because, whether you know what the laws say or not, you signed that agreement and you will be held to the standards spelled out in the federal and state statutes.

2. Call your liability insurance.

Be proactive.  Contact your liability insurance agent before you get the notice of an onsite review from PCG.  Have a frank, open discussion about these upcoming onsite reviews.  Explain that you want to know whether you policy covers attorneys’ fees and whether you can choose your attorney.  If your policy does not cover attorneys’ fees or does not allow you to choose your own lawyer, beef up your liability insurance plan to include both.  Believe me, the premiums will be cheaper than an attorney from your own pocket.

3. Be confident.

Presentation matters.  If you whisper and cower before the PCG reviewers, you will come across as weak and/or trying to hide something.  Be polite and forthcoming, but provide the information that is asked of you; do not  supply more information than the reviewers do not request.

I always tell my clients before their deposition or a cross examination by the other side, “Answer the question that is asked.  No more.  If you are asked if your favorite color is blue, and you favorite color is red, the correct response is “No,” not “No, my favorite color is red.”  Do not over-answer.

If you do not believe that you can be confident, ask your attorney to be present.  I had someone tell me one time that he did not want an attorney present because he felt that the auditors would think he was hiding something and he did not want to appear litigious.  I say, this is your company, your career, and your life.  If you need the support of an attorney, get one.  Whenever I give this advice, I try to imagine that I am telling the same advice to my mother.  My mother, bless her heart, does not have the confidence to stand her ground in high pressure situations.  She would rather yield her position than be the least bit confrontational.  If that also describes you, have your attorney present.

4. Know your rights.

What if you fail the onsite review?  Can you appeal?  You need to know your rights.  When you get a notice from PCG that an onsite review is scheduled, contact your attorney.  Make sure that BEFORE the onsite review, you understand all the possible consequences.  Knowing your rights will also help with #3, confidence.  If you know the worst case scenario, then you stop creating worse case scenarios in your mind and become more confident.

Ready or not, the PCG reviews are coming, so get ready!