West Virginia Department of Health and Human Resources: An Inside Look at Medicaid Credit Balance Auditing HMS Inc High Point Dr Irving, TX 75038

2 HMS is contracted with WV DHHR to conduct Medicaid credit balance reviews in order to determine if overpayments exist. HMS reviews all acute care facilities throughout the state of West Virginia. HMS also reviews facilities in surrounding states such as KY, OH, PA, etc. HMS has had a relationship with WV DHHR for over 20 years. Currently serves 24 State Medicaid agencies, Medicaid Managed Care Organizations (MCO) and Commercial Insurance Plans 14 years of experience working with providers on credit balance audit projects HMS Background

HMS Credit Balance Audit (CBA) Overview Credit Balances Audits (CBAs) are focused on financial reimbursements to the provider Primarily the CBAs are focused on reviewing the Provider’s Accounts Receivables (AR), Remittance Advices (RA), Explanation of Benefits (EOB) and miscellaneous relevant financial documents. Experience determining and communicating with the provider the root cause of the identified overpayments or accounts resulting in credit balances

4 A credit balance occurs when the sum of payments received plus adjustments exceed the total charges on a claim Just because an account is sitting in a credit balance does not mean money is due back to the payer Common causes of credit balance include: –Payments from third party payors and from Medicaid –Duplicate Medicaid payments –Charge reversals/adjustments/transfers –Duplicate adjustments made to an account What is a Credit Balance?

5 Approach COB Retroactive payments Duplicate payments Incorrect payments ROOT CAUSES 35% 65% MONETARY NON-MONETARY HMS provides a root cause analysis to prevent future credit balances. Inaccurate postings Charges written off in excess of amounts actually billed Provider A/R collection systems modeling net revenue at the time of billing Not all overpayments are credit balances; not all credit balances are overpayments

Three Types of Credit Balance Audits –Amnesty/Self Disclosure Review –On Site Review –Remote/Desk Review

7 Hospital Payment Report –Quarterly Medicaid spend –In state vs out of state Self Disclosure Letter –30 day deadline –Refund Resource Worksheet –Electronic voids/Live check refunds Final Report –Electronic voids verified –Live checks received –Final report and live checks forwarded to the state Credit Balance Audit Process: Amnesty/Self Disclosure

Credit Balance Audit Process: On Site On Site Notification Letter –Initial Contact –Official Request for (systems-generated) credit balance report –Pre Review Attachment –Two week deadline to submit documentation –Analyze credit balance report –Review scheduled On Site Review –Entrance Conference –Review of patient accounts –Identify refunds –Exit Conference –Overpayments refunded within 14 days –Final report and live checks forwarded to the state

Credit Balance Audit Process: Remote/Desk Notification Letter –Same process as on site –Determine that on site review is not warranted –Documents requested –< 60 accounts Remote/Desk Review –Documents received in the Atlanta office –Review conducted within 1 week of receipt of documents –Findings communicated to provider contact –Overpayments refunded within 14 days –Final report and live checks forwarded to the state

10 Open communication with providers throughout the audit process Root cause analysis assists providers in preventing future overpayments Insure providers are up to date on the latest billing and reimbursement methods utilized by WV DHHR Partner with providers to establish an efficient process for conducting credit balance reviews Credit Balance: Provider Education

Credit Balance Audits: Key Contacts Self Disclosure Reviews – Eve Garcia –T: On Site Reviews – Paul Triay – Audits Supervisor – Lorenzo Jackson – x2109 Program Director – Rick Levock

12 Questions