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

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

HMS - RAC Contractor

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

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

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

Five-step review process

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

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

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

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

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

Complex Reviews

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.

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

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

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

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

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

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

Reconsideration of Findings

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

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

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

Oklahoma Health Care Authority Appeals and Payments

Appealing the Findings Big idea slide

Refunding the identified Overpayment

Providers are encouraged to call HMS’ Provider Services to discuss and resolve issues OHCA RAC toll free number: 855-845-1118 Email: okrac@hms.com Web site: www.Medicaid-rac.com/Oklahoma-providers

Questions and Comments

Contact Information Nancy Gress Program Director HMS 816-443-2674 ngress@hms.com Caroline Landrum Program Manager 972-916-2081 caroline.landrum@hms.com Caleb Kinzer Senior Director, HMS 612-741-4998 Caleb.Kinzer@emailhdi.com Marnie Basom Vice President, HMS 208-639-8202 mbasom@hms.com