Category Archives: Clinical Policy 4A
This blog pertains to all Medicaid providers regardless the state and regardless the Medicaid service provided.
Heard of the “Way Back Machine?” Perhaps, you should have!!!
You are a Medicaid provider, and you get a Tentative Notice of Overpayment (TNO) based on a Medicaid post-payment review by Public Consulting Group (PCG) or HMS in the extrapolated amount of $800,000 based on a sample size of 100 dates of service (DOS) and multiplied out to some extrapolation universe. You look at the extrapolation data and determine tha you were not even paid $800,000 during the time frame PCG determined was the universe. Or you say…What???…My documents complied with policy!
What do you do?
Sound like a horrible SAT question? Or sound like reality?
Hopefully you answered the former, but if you answered the latter, read on…
You’ve read my blogs before and understand the importance of appealing PCG or HMS’ extrapolated audit. But you do not have the financial means to hire an attorney. Or you honestly believe that if the Department of Health and Human Services (DHHS) reviewed your documents that its employees would also agree that PCG or HMS was wrong. Or you, personally, want to self-audit to determine the veracity of the audit. Or for whatever reason, you want to know whether PCG or HMS was correct for your own well-being.
How do you self-audit….the audit?
This may be one of the best “tips” I have given… (sorry for tooting my own horn, but, seriously, this blog can be helpful! I had a client that pointed out he/she had no idea about this “tip.”)
PCG and HMS conduct post-payment reviews. This means that PCG and HMS are looking at 1-2-3-year-old medical records.
Think about how quickly Medicaid changes. Now think about the number of times in which the DMA Clinical Policy applicable to your practice has been revised in the last few years.
When I say DMA Clinical Policy, I mean, if you provide Outpatient Behavioral Therapy, Policy 8C is applicable. If you provide dental services to Medicaid recipients, then Policy 4A is applicable. If you provide durable medical equipment (DME) to Medicaid providers, then Policy 5A is applicable. For a full list of the NC Medicaid policies, please click here.
The DMA Clinical Policies change significantly throughout the years. For example, DMA Clinical Policy 8A, revised January 1, 2009, allowed Community Support for adults and children. Yet Policy 8A, revised August 1, 2013, does not even allow Community Support (obviously Community Support was disallowed prior to August 2, 2013, but I am making a point). Also, now we have 16 unmanaged outpatient behavioral therapy visits for children, whereas a couple of years ago we had 26 unmanaged visits.
The point is that when PCG or HMS audits your particular service, the auditors are not always experts in your particular service, nor experts in your particular service’s Clinical Coverage Policy. See my blog on Dental Audits Gone Awry. In this blog I show the required (or lack thereof) education/experience to become a PCG auditor.
Therefore, it is imperative that you have access to the applicable Clinical Coverage Policy applicable for the DOS audited.
But, if you google 2009 clinical policy for NC Medicaid dental services, you can’t find it.
So how are you supposed to get access to these old policies that are being used (or mistakenly NOT being used) in Medicaid audits for the older DOS?
It is called: The Way Back Machine.
I know, cheesy! But I did not name it.
The “Way Back Machine” website looks like this:
The beauty of the “Way Back Machine” is that you can go to any current website. Copy the internet address. Paste that internet address into the “Way Back Machine” where you see “Way Back Machine” and a white box appears in which to type the website address. Type in the address, and hit the button “Take Me Back.” VOILA…time travel!!!!
Small Tip: I have found that if I use the internet address for the specific policy for which I am researching, I am less successful than if I use the general DMA Policy address found here. Once you get to the appropriate year on DMA’s general policy website, you can click on the specific policy in which you are interested.
Using the “Way Back Machine,” you can go to the DMA Clinical Policy (for whatever Medicaid service) applicable years ago.
You should never need to go more than 3 years back, as Recovery Audit Contractors (RACs) without permission by DHHS, cannot audit DOS more than three years ago.
But, you need to review the Clinical Policy for [fill-in-the-blank] Medicaid service 2 years ago? No problem! Use the “Way Back Machine” and travel back in time.
Wouldn’t it be great if we could travel back in time “for real?” Prior to RACS…prior to PCG…prior to HMS….? We need a “Way Back Machine” for Medicaid providers (and me) “for real!”
A dental practice was audited by Public Consultant Group (PCG). Here is their story: (Insert a Dum, Dum, Dum).
For those of you who do not know who PCG is: CONGRATULATIONS!
But there are those of us who know that PCG is a hired contractor by the state or the Division of Medical Assistance (DMA) to investigate providers who accept Medicaid in North Carolina to detect clinically suspect behaviors or administrative billing patterns, which could indicate potentially abusive or fraudulent activities.
Whew!! Sounds serious!!
I am SURE that, for such a serious mission, PCG employs only the most-highly competent employees who are super, duper knowledgeable about the esoteric idiosyncrasies of the Medicaid system, the appropriate policy(ies),and federal and state rules and regulations, right?
Hmmmm…out of sheer curiosity I googled employment opportunities at PCG. I found a position in Albany, NY for an “Instructional Trainer.” Duties include:
“Coaches agencies and providers on programs and information to ensure compliance with departmental, state, and federal laws, rules, regulations, guidelines, processes, and procedures.”
Dag on!!! Shut the front door! This person will be coaching agencies and providers, ensuring compliance with laws, rules, regulations, guidelines….SURELY this person must be a lawyer, right????
So then I looked at the “required experience:”
- BS degree in a related field preferred
- Experience in development and delivery of instructional materials or training
- Experience in health & human services is desirable
- Experience working in a team-oriented, collaborative environment
- Advanced Knowledge of Curriculum Design and Training Delivery
- Advanced Knowledge of Office Skills such as Word Processing and Data Collection
- Advanced Knowledge of the Principles for Providing Customer Service
A BS degree is a related field preferred??
First, what is a related field for regulations and compliance? Political Science?
Folks, I double-majored in English and Political Science and I can promise you that after graduating from NCSU with a double major in English and “Poli Sci” I was NOWHERE competent enough to handle a Medicaid audit of a provider. I may have been able to draft a darn good essay or quote the U.S. Senators and their bipartisan affiliations, but a Medicaid expert, I was not. And this position was for an “Instructional Trainer!” A TRAINER!! As in, one who trains. Implicit in the job title is “One who has been trained” or “One who has the knowledge to train.”
I give this background to set the stage:
On one side: Dentists who have been managing a successful dental practice for years and years after attending college and dental school.
And on the other side: A college Political Science major who is able to recite all the states and its capitols and all the governors of each state (This is not to say that all employees at PCG are inept…or not qualified for their particular position. I actually know a couple of PCG employees of whom I think highly (this is not directed toward you, my fine two friends). This is merely a generalization and stage-setting for the all-too-common errors I see committed by the “entry-level” auditors).
A well-established dental practice. All the walls are wooden (painted white) and there are 200+ handprints on the lobby wall with all the little pediatric customers’ names on them. There is a waiting room with toys and books.
Act 1: A few entry-level PCG auditors knock on the door of the dental practice (They don’t actually knock, because it is a dental practice, not a home, but you get the drift).
Receptionist: How may we help you?
Auditor 1: We are here to conduct a Medicaid post-payment audit.
Receptionist: Huh? (With an open, gape-jawed expression)
Auditor 2: A post-payment Medicaid audit.
Auditor 1: We need to see all the documents of your Medicaid clients from February 2011 through May 2011.
All right, folks, I am sure you get the point. So the audit occurs and a few months later, the dental practice receives a Tentative Notice of Overpayment for $300,000.00. The #1 main reason PCG found noncompliance was:
“The attending provider number billed does not match the individual dentist who rendered the service and does not support service billed. Citation: Clinical Coverage Policy No. 4A: January 1, 2011 Attachment A.1 Instructions for filing a Dental Claim 53-56…”
Now, mind you, in the DMA Clinical Policy No. 4A, revised March 1, 2013, the policy states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number must correspond to the signature in field 53.)”
In 2013, it is quite clear that the attending provider and the provider rendering the services must be identical. But this audit was a post-payment review, meaning that the documents audited were from 2011, not 2013.
In 2011, the DMA Clinical Policy No. 4A, revised January 1, 2011, states “Enter the attending provider’s NPI for the individual dentist rendering service. (This number should correspond to the signature in field 53.)”
See the difference? (One of these things is not like the others).
Must v. Should
Must equals no other choice. Should denotes guidance; simply a suggestion.
However, think of this, if you were a college graduate who majored in Political Science and were now auditing Medicaid providers, would you think to distinguish the difference between “should” and “must?”