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OMIG\HMS Integrated Reviews & Provider Portal Cerebral Palsy Associations of New York State April 2011.

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Presentation on theme: "OMIG\HMS Integrated Reviews & Provider Portal Cerebral Palsy Associations of New York State April 2011."— Presentation transcript:

1 OMIG\HMS Integrated Reviews & Provider Portal Cerebral Palsy Associations of New York State April 2011

2 Today’s Objectives Describe OMIG’s new approach to payment recapture Demonstrate how this approach can help optimize recoveries and minimize abrasion Provide an overview of the OMIG/HMS Provider Portal 1

3 Where We Are Now 2 PI Provider self-disclosure Onsite and desk reviews Credit balance reviews Data mining Long-term care review Institutional reviews Data matching Cost avoidance Third party reviews Estate and casualty recovery Direct billing Disallowances TPL

4 Where We Are Headed 3 Disallowances Onsite and desk reviews INTEGRATION Provider disclosure Payment integrity reviews e-Reviews Fraud referrals Provider scoring Institutional reviews Free standing clinic reviews Long-term care reviews Direct billing Estate and casualty recovery Data matching Cost avoidance Third party reviews Data mining

5 ACA Increases Focus on Program Section 6402(a) of Affordable Care Act (ACA) requires providers to “report and return” overpayments Section 6411(a) requires states to establish contract(s) with one or more Medicaid Recovery Audit Contractors Funding to combat fraud, waste and abuse 4

6 NY Medicaid RAC Program OMIG has designated HMS as the New York Medicaid RAC with CMS’s approval of the SPA Integrated approach shares data across programs –Maximize identification of payment issues –Reduce future overpayments –Minimize provider burden The “integrated approach” will be a central piece to New York OMIG Medicaid RAC Program 5

7 Integrated Approach 6

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12 e-Reviews and Data Mining Uses paid claims data from third party payors and other external data –Commercial –Medicare –Provider A/R (Credit & Debit Balances) Allows for validation of overpayment at time of data mining Notifies providers via mail and portal Recoveries may be initiated electronically through MMIS 11

13 e-Reviews and Data Mining (cont.) More emphasis on provider compliance and program oversight Each overpayment is reviewed at the claim level 12 Drives the integration of TPL and PI through data mining

14 Integrated Approach 13

15 Integrated Approach 14

16 Integrated Approach 15 Sentinel Effect = Improved Provider Billing

17 Question: How are we going to work with the providers to help consolidate and streamline review distribution, reconciliation and recovery processing? Answer: OMIG/HMS Provider Portal 16

18 Overview of the Provider Portal The Provider Portal is a web-based application that will allow providers a single point of entry for multiple OMIG reviews The provider portal is designed to accommodate multiple functionalities –Third Party Reviews –Payment Integrity Reviews –Provider Self-Disclosures –Medicaid Credit Balance Reporting 17

19 Accessing The Provider Portal 18 Web-based with 128-bit security encryption Login for existing users and requesting a user account

20 New User Registration 19 Select Registration Type to pull up the appropriate registration form Once the registration form has been submitted the new user will contacted by HMS to verify information

21 First Time Access 20 Enter a new personalized password and confirm Enter the Current Password given to the provider by HMS during the registration process Select security questions and answers Click OK

22 Home Page 21 Select Application/Project

23 Third Party Reviews 22 Once you have selected the appropriate Third Party Review click to open Each Third Party Review is assigned a “cycle number”. “Cycle Search” allows the user to search for a specific review.

24 Third Party Reviews (cont) 23 “Recipient Search” function allows the user to pull up all the claims that appeared on Third Party Reviews that belong to a specific patient Click to view claim detail

25 Third Party Reviews (cont) 24 Click to view claim detail “Claim Search” function allows the user to pull up a specific claim that appeared on a Third Party Review

26 Responding to Third Party Reviews (cont) 25 Click on the down arrow of “Provider Action/Reasons” to select the appropriate Action/Reasons code Enter comments regarding the claim in the “Provider Comments” box Click “Ok” to save the Action/Reasons code and Provider Comments or click “Cancel” to discard changes and exit. Information identifying cycle number, recipient, and third party coverage Claim Information

27 Payment Integrity Reviews Types of Payment Integrity Reviews –Automated Reviews (e-Reviews) Consists of overpayments that can identified with extremely high accuracy Provider will be given 30 days to review findings –Complex Reviews Potential overpayments where additional information is required to make a clear determination Providers required to submit documentation to HMS HMS reviews the documentation and makes a determination Reviews will be sent to providers in a similar fashion as TPR –Target overpayments through data mining –Upload targets to the Portal and notify providers –Providers given clear instructions on how to satisfy each type of review 26

28 Self-Disclosures 27 Upon logging into the provider, users with appropriate will see the Self- Disclosure application listed on their home page. Click “Select” to access the application.

29 Self-Disclosures – Input 28 Enter recipient’s information Enter primary payor and payment information (if applicable) Enter basic claim information needed to identify the claim Enter refund amount and reason(s) for overpayment As refunds are entered and saved, they appear at the bottom of the screen Click “Submit” to submit the report to the “Supervisor” for final review

30 Self-Disclosures – Search 29 Each user is allowed to query for refunds they entered and/or submitted. Users with “Supervisor” access will be able to query all refund entries for the given provider/facility. Query options. Enter the search criteria and click “Search” Search results are returned at the bottom of the page Click “Export” to export search results to an Excel spreadsheet Click “Details” to view full information on file

31 Self-Disclosures – Attestation 30 Only the users with “Supervisor” access will be able to formally submit self- disclosures to OMIG-HMS. When submitting the final report, the “Supervisor” will be asked to attest to the information being submitted.

32 Medicaid Credit Balance Reporting Batch Reporting –Will give providers the ability to upload completed worksheets with proper attestation, eliminating claim by claim data entry and reporting –Supply a report template for providers to use –May require providers who chose to use batch reporting to under-go acceptance testing to verify correct formatting, accuracy of data, etc. Will mirror OMIG initiative to prompt self-disclosures 31

33 What to Watch for in 2011 Third Party Reviews –Outreach underway to re-register providers to the OMIG-HMS Portal –Anticipate uploading the first Review to the portal around March 21 th Self-Disclosures –Development completed –Currently in the User Acceptance Testing (UAT) Phase –Looking for initial rollout to a small group of hospitals around April 25 th –Will seek feedback from the early adopters Credit Balance Reporting –Currently in the design phase –Anticipating 3 month development and testing Payment Integrity Reviews –Currently in the design phase –Anticipating 6 month development and testing 32

34 Timeline March 21, 2011 Third Party Reviews April 25, 2011Self-Disclosures July 1, 2011Credit Balance Reporting October 1, 2011Payment Integrity Reviews 33

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