1. Provider Outreach & Education Presentation
Oklahoma Health Care Authority
Recovery Audit Contract
Provider Outreach & Education Presentation
March 8, 2016

2. HMS – RAC Contractor
Provider Portal
5-step review process
Complex Reviews
Reconsideration of Findings
OHCA: Appeals and Payments

3. HMS - RAC Contractor

4. About HMS We provide cost containment services for healthcare payers
We help ensure that claims are paid correctly (program integrity) and by the responsible party (coordination of benefits)
As a result, our clients spend more of their healthcare dollars on the people entitled to them

5. Provider Portal
The Provider Portal is a secure website that allows providers to manage their RAC reviews
More than 15,000 providers currently use HMS’s Provider Portal
Contact information can be updated by providers
Contains HMS contacts

6. Using the Portal Providers are able to:
See the claims included in the record request letter
Monitor status of all claims including:
Receipt of the medical record
Status of findings
Status of reconsideration if submitted
Copies of letters to the provider
Run reports

7. Five-step review process

8. 1) Analysis and Targeting
Program Analysis
Understanding Work in Progress
Data Mining
Review/Approval

9. 2) Record Request Provider Contact Request Letters Tracking/Follow-up
Electronic Records

10. 3) Review and Audit RN/Coder Review Physician Referral
Overpayment/Underpayment Calculation
QA and Client Review

11. 4) Notification and Recovery
Notification Letter
QA/Certified Mailing
Reconsideration/Appeal
Recovery Support

12. 5) Education and Process Improvement
Notification Letter
Provider Meetings
Program Recommendations
Newsletter/Website

13. Complex Reviews

14. Clinical Claim Review
Clinical Claim Review uses proven algorithms that allow us to request medical records only for claims that seem likely to include improper payments based on previous claims.

15. Overview of Review Process
Program Analysis
Data Mining/Scenario Design
State Approval
Analysis
And Targeting
Provider Contact
Record Request/Receipt
Tracking/follow up
Record Request
RN/Coder Review
Physician Referral
QA and Client Review/Approval
Review/Audit
Notification Letter
Reconsideration/Appeal
Recovery Support
Notification
and Recovery
Provider Association Meetings
Program Recommendations
Newsletter/Website
Education,
Process Improvement

16. Record Request OHCA approves claim selection
Letters generated and mailed certified
Provider has 30 days from receipt of letter to submit medical records
All time frames start from receipt date

17. Record Receipt Records bar-coded in the mail room
Each record is scanned
Hard copy of record stored
Status of record marked in the portal
Issues to date

18. Technical Denial
No records submitted for a claim within 30 days from proof of letter receipt
Records submitted not adequate for determining appropriateness of setting
Provider non-responsive to request for missing records

19. Review by HMS
Medical Records received and scanned to be attached to the provider number
Reviewers commence reviewing the records using Milliman as a guideline
No time constraint to complete review and return findings to provider

20. Results of Record Review
Completed clinical review results:
No finding – no notification sent
Finding – detailed explanation included in findings letter
Provider Portal Updated
Letter mailed to provider when all claims reviewed and results available

21. Reconsideration of Findings

22. Results Received
Provider receives certified letter with detailed results for every claim with findings
Listing provided with every claim
Provider has 20 days from date of receipt to submit an informal reconsideration

23. Informal Reconsideration
Include any/all relevant documents necessary to substantiate your claim or clear any misunderstandings
Clinical review of new documentation to determine if the finding will change
Provider will receive a response letter when ALL informal reconsiderations are completed

24. What next? Claims with the finding upheld will be marked as such
The provider can now pay the overpayment amount or –
Request a formal appeal within twenty (20) days of receipt of the findings letter in accordance with Oklahoma Administrative Code (OAC) 317:2-1-7

25. Oklahoma Health Care Authority
Appeals and Payments

26. Appealing the Findings
Big idea slide

27. Refunding the identified Overpayment

28. Providers are encouraged to call HMS’ Provider Services to discuss and resolve issues
OHCA RAC toll free number:
Web site:

29. Questions and Comments

30. Contact Information
Nancy Gress
Program Director HMS
Caroline Landrum
Program Manager
Caleb Kinzer
Senior Director, HMS
Marnie Basom
Vice President, HMS