B. Claims Verification Primary Review: Review by the Contractor who receives a randomized sample review of the percentage of claims paid. C. Claims Verification Secondary Review: Review by the Authority of a sample of the Claims Verification Primary Reviews conducted by the Contractor. V. STANDARDS A. PRIMARY CLAIMS VERIFICATION: There are various types of claim reviews based on data findings, corrective action plans, directives from regulatory agencies, at risk situations and information finding investigations. Responsibility for primary claims verification is delegated to the Contractor. Each will conduct claims reviews according to a process that is directed by: The Authority Their governing body, Compliance Officer, regulatory Authority (i.e., CARF) or other entity. As a claims review process example, the following standards apply to the required Michigan Department of Community Health (MDCH) Detroit Wayne Mental Health Authority Claims Verification Review Tool for Medicaid Services Verification. 1. Schedule: Medicaid and other claims will be reviewed quarterly by each Contractor utilizing the following schedule: Reporting Period Service Months Being Reviewed Audit Review Time Period Quarter 1 October December January 1 March 31 Quarter 2 January March April 1 June 30 Quarter 3 April June July 1 September 30 Quarter 4 July - September October 1 December 31 2. Sampling: Contractors will randomly sample claims on a quarterly basis, including Medicaid and any commercial health insurance claims (i.e., HMO). 3. Verification: a. The MDCH Medicaid Services Verification process will include record reviews for verification of the following elements: i. Determination of whether services provided are eligible for payment as listed in the Medicaid Provider Manual. ii. Determination of whether the individual receiving the service was eligible at the time of service. Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 2 of 7
iii. Determination of whether services provided were authorized in the Person Centered Plan. iv. Determination of whether there is documentation that services claimed were actually provided in the amount, scope and duration authorized. v. Determination of whether the provider held the necessary credentials to provide the service. vi. Determination of whether the dates of services provided and submitted on claim documents accurately correspond with those in the clinical record. vii. Verification of whether any third-party fees collected were offset against expense. 4. Evaluation of Audit Findings: a. Contractors using the appropriate review tool by the specified due date. The report will contain the following: i. Summary of the number of claims examined. ii. Summary of claims found to be valid, invalid or in question. iii. Any unusual findings detected. iv. Cause(s) of discrepancies and a plan of correction to remediate problems found during the review. v. Findings that are suggestive of abuse or fraud and any activity that has occurred so far with the Compliance Officer. b. The Authority s Quality Assurance Administrator will analyze and evaluate the Contractor data, with the following possible dispositions: i. Acceptance of report with no further action needed until the next audit. ii. Provision of organization specific/group technical assistance. iii. Requirement of a plan of correction with monitoring and documentation of findings until the situation is resolved. iv. Consultation with the Authority s Quality Management Unit Director/Compliance Officer. B. CLAIMS VERIFICATION SECONDARY REVIEW: Secondary claims verification audits will be performed by the Authority Quality Management Unit under the direction of the Performance Monitor Administrator. The purpose of the secondary audit is to confirm that the primary claims audit findings are accurate and consistent with standards. The audit process will also include verification that any prior plans of correction for errors found in prior audits were completed. Performance Monitors will be trained in the use of review tools and inter-rater reliability will be a part of the process. Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 3 of 7
The secondary claims verification process will include the following: Upon request, Contractors will prepare a list of all claims previously reviewed during the designated time period and copies of the primary review findings for each claim. The related clinical record will be available for the Authority s audit team to review. 1. The Authority s Performance Monitors will conduct a secondary verification of at least 5% of the claims that were audited by the affiliates during the designated time period. 2. The secondary verification reviews will occur during the Authority s Quality Management annual quality monitoring site visits or at other designated times. 3. The secondary verification review tool will mimic the primary review tool, with additional elements as needed. Revisions to the process/review tool will occur according to stakeholder feedback. 4. The secondary review will compare the Performance Monitor findings to the Contractors findings of each claim audited during the primary audit process for: a. Determination of whether services provided are eligible for payment as listed in the Provider Manual. b. Determination of whether the individual receiving the service was eligible at the time of service. c. Determination of whether services provided were authorized in the Person Centered Plan. d. Determination of whether there is documentation that services claimed were actually provided in the amount, scope and duration authorized. e. Determination of whether the provider held the necessary credentials to provide the service. f. Determination whether the dates of services provided and submitted on claim documents accurately correspond with those in the clinical record. g. Validate all necessary documentation to support the claim. 5. Follow-up Regarding Findings: A written report will be provided to each MCPN and their Contracted Providers, Substance Abuse provider agencies, as well as Direct Contractors, identifying the findings of the secondary review. Discrepancies in numbers and types of deficiencies will be noted. A written request for a corrective action plan will be provided as needed and evidence will be sought to confirm that the identified deficiencies have been corrected. An aggregate report of all claims reviewed and action plans and recommendations will be provided by the Performance Monitoring Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 4 of 7
Administrator to the Director of Quality Management and the Quality Assurance Administrator. If needed, the Performance Monitoring Administrator will report suspicion of fraud or abuse to the Director of Quality Management/Compliance Officer. C. REPORTING OF FINDINGS: Findings from the MDCH Medication Claims Verification audit and any other Authority directed claims audits are to be reported out to stakeholders. Authority Report of Findings: 1. Primary Claims Reports: The Quality Assurance Administrator will provide a quarterly aggregate report of the findings of the MDCH Medicaid Services Verification Primary Review. This report will include compliance rates, corrective action plans and trends toward improvement. The report will be prepared for presentation to consumers, consumer advocates, Authority staff, the Compliance Officer, the Total Quality Management Committee of the Board of Directors, the Quality Improvement Steering Committee, the Quality Technical Assistance Workgroup and to other stakeholders, as appropriate. 2. Secondary Claims Reports: The Performance Monitoring Administrator will provide an aggregate report of the findings of the Claims Verification Secondary Review by the Performance Monitors to the Director of Quality Management. This report will include the error rates, corrective action plans, disciplinary plans and improvements across the affiliation. The report will be prepared for presentation to consumers, consumer advocates, Authority staff, the Compliance Officer, the Total Quality Management Committee of the Board of Directors, the Quality Improvement Steering Committee, the Quality Technical Assistance Workgroup and to other stakeholders, as appropriate. 3. Michigan Department of Community Health (MDCH) Annual Report: The Quality Assurance Administrator will provide an annual aggregate report of the findings of the Claims Verification Review Tool for Medicaid Services Verification according to the directives provided by MDCH. 4. MCPNs and their Contracted Providers, Substance Abuse Provider agencies and their affiliates, as well as Direct Contractor Reports of Findings: Reports of the findings of any primary and secondary claims verification findings are to be provided to their governing body, Compliance Officer, staff, subcontractors, consumers and other stakeholders, as appropriate. Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 5 of 7
VI. VII. VIII. IX. QUALITY ASSURANCE/IMPROVEMENT The Authority shall review and monitor contractor adherence to this policy as one element in its network management program, and as one element of the QAPIP Goals and Objectives. The MCPNs, their subcontractor s and direct contractor s quality improvement program must include measures for both the monitoring of and the continuous improvement of the program or process described in this policy. COMPLIANCE WITH ALL APPLICABLE LAWS Agency staff, MCPNs, their subcontractors, direct contractors, and Substance Abuse Coordinating Agencies (CAs) and their subcontractors are bound by all applicable local, state, and federal laws, rules, regulations, and policies, all federal waiver requirements, state and county contractual requirements, policies and administrative directives in effect as may be amended. LEGAL AUTHORITY AND REFERENCES Authority staff, MCPNs and their contracted providers, Substance Abuse provider agencies and Direct Contractors are bound by all applicable local, state and federal laws, rules, regulations and policies, all federal waiver requirements, state and county contractual requirements, policies and administrative directives in effect and as may be amended. EXHIBIT(S) The Detroit Wayne Mental Health Authority Claims Verification Review Tool for MDCH Medicaid Services Verification. Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 6 of 7
Please Check: Policy: New Revised Annual Review Effective Date: Reviewed By: Reviewed Date: Fiscal Year: 2/13/2012 Starlit Smith - QM Muddasar Tawakkul - Compliance Rolf Lowe - Legal 12/17/2014 2015 Revised (Claims Verification) 12/17/14, Replaces policy last reviewed (3/1/2012) Page 7 of 7