GEORGIA MEDICAID P ROGRAM I NTEGRITY AND RAC: W HAT Y OU C AN E XPECT IN 2014 P RESENTATION T O T HE H OME T OWN H EALTH 14 TH A NNUAL F ALL C ONFERENCE C ALLOWAY GARDENS GA, N OVEMBER 14, 2013

MEDICAID RAC: OVERVIEW Perform audits to identify mispayments Includes both FFS and CMO claims Five-year “look back” Medical director and certified coders required Provider education and outreach Coordination with other audit contractors and programs Limitation on medical record requests Administrative review process 2

MYERS AND STAUFFER LC CPA firm with 18 offices nationwide Healthcare consulting, auditing and reimbursement services Strictly government clients (45 States and Fed government) Selected as Georgia Medicaid RAC effective April 2,

MSLC GEORGIA RAC TEAM Project Director – Michael Johnson, CPA and CFE Project Manager – Scott Smeal, JD Medical Director – Joel Goldstein, MD Analysts, Nurses, Coders, Data Analysts Additional Staff as Needed 4

RAC AUDITS Developed in consultation with and subject to the approval of the DCH IG Three basic types:  “Automated” or claims-based, without medical records  “Complex” with records review (desk or onsite)  Self-audits Unbiased review to determine mispayments (both overpayments and underpayments) 5

AUDIT PROCEDURES Complex audits typically begin with request for records Initial Findings Letter Provider can agree or request administrative review Final Decision Administrative Appeal in accordance with Chapter 500, Part I, Policies and Procedures for Medicaid/Peachcare for Kids™ 6

FRAUD REFERRALS MSLC required by contract and Federal law to refer instances of suspected fraud Referrals are made to DCH Deputy Inspector General DCH decides to refer to MFCU and/or other appropriate Federal and/or State law enforcement or regulatory agencies 7

PROVIDER EDUCATION AND OUTREACH Toll-Free Number (855) MSLC RAC website: Frequently asked Q & A Points of Contact Audit Policies and Protocols Audit Agenda News and Updates 8

RAC PROVIDER RELATIONS (RPR) ADVISORY COMMITTEE Established to promote provider input about general RAC issues 15 members, including 4 from DCH, 4 from MSLC and 7 from the provider community Quarterly meetings One-year term No compensation 9

ACTIVE AUDITS Hospital transfer pricing Patient liability Fair rental value (FRV) Neonatal Intensive Care Unit (NICU) services Hospital outpatient related to inpatient Physician services: allergy, drug screen, global services 10

PRELIMINARY AUDITS DME DRG validation Home health services Hospice Duplicate payments NCCI/MUE 11

MYERS AND STAUFFER LC Located in Georgia-Pacific Center at 133 Peachtree Street, NE – Suite 3150 Atlanta, GA (404) (404) (FAX) Toll-Free (855) Michael D. Johnson or Scott A. Smeal 12

QUESTIONS? 13