Corrective Action for Medicaid/NCHC QC Errors and Deficiencies Prepared and Presented by Shara Britt, Assistant Chief DMA Quality Assurance and Special Projects Section

DMA Quality Assurance Reviews Medicaid Eligibility Quality Control (MEQC) Monthly MEQC reviews- specific populations or certain geographic areas will begin again with FY 2016 Focused reviews –planned by state/approved by CMS or directed by CMS (currently being done for FY2014 – FY2016) Payment Error Rate Measurement (PERM) FY2013 - most recent PERM cycle completed for NC FY2014-FY2016- PERM eligibility reviews postponed by CMS until FY2017 for all states Medicaid and CHIP identified as susceptible programs

FY2014-FY2016 - Focused Medicaid/NCHC Reviews CMS has given states specific sampling and review requirements Four rounds of reviews(six-month sampling periods) First two rounds focused on MAGI Third round will focus on MAGI and non-MAGI Fourth round - CMS still has to provide requirements and type of universe

PERM FY2013 Medicaid Error Rates Medicaid actives- 972 cases reviewed, 31 error cases, 40 cases with deficiencies(4.56% payment error rate; 1.34% active case error rate) Medicaid negatives –384 cases reviewed, 91 error cases, 40 cases with deficiencies (23.74% negative case error rate) Note: Deficiencies/technical errors were required to be reported to CMS but did not factor into error rates

PERM FY2013 NCHC Error Rates NCHC actives- 504 cases reviewed, 32 error cases, 11 cases with deficiencies(3.21% payment error rate; 6.34% active case error rate) NCHC negatives –204 cases reviewed, 91 error cases, 40 cases with deficiencies (20.12% negative case error rate) Note: Deficiencies/technical errors were required to be reported to CMS but did not factor into error rates

Round 1 FY2014-2016 Error Rates Medicaid actives- 44 cases reviewed, 2 error cases (4.5% active case error rate) Medicaid negatives –126 cases reviewed, 55 error cases (44% active case error rate) NCHC actives – 5 cases reviewed, 0 error cases(0%) NCHC negatives- 0 cases reviewed Note: Deficiencies/technical errors were not required to be reported to CMS. No payment error rate calculated.

Round 2 FY2014-2016 Error/Deficiency Rates Medicaid actives- 75 cases reviewed, 4 error cases, 26 cases with deficiencies (40% cases with errors or deficiencies) Medicaid negatives –25 cases reviewed, 0 error cases, 15 cases with deficiencies (60% cases with errors or deficiencies) NCHC actives – 75 cases reviewed, 9 error cases, 23 cases with deficiencies (43% cases with errors or deficiencies) NCHC negatives- 25 cases reviewed, 0 error cases, 15 cases with deficiencies (60% cases with errors or deficiencies)

Review Requirements Eligibility verification and processing Income and resource calculations Appropriate and accurate notices Timeliness of processing(actives and negatives) Sanctions Transfers to FFM for negative actions

Reasons for Errors/Deficiencies Incorrect program or program classification Citizenship/identity not verified OVS not completed and reviewed OVS not used for verification of income Income of budget unit member not used Income calculation errors Residency not verified Insurance information not entered into NCFAST

Reasons for Errors/Deficiencies No denial or termination notice sent Timely notice does not show 10th work day or shows incorrect date for the 10th work day Terminated prior to 10 work days Incorrect reasons on denial or termination notices Timeliness of actions Resources not verified or excess resources

Notification of Errors/Deficiencies Notification of errors or deficiencies (technical errors) is sent by DMA Quality Assurance(QA) via DMA-7002, Active Case Error/Technical Error Report or DMA-7004, Negative Case Error/Technical Error Report DMA-7001, County Department Report of Errors and Corrective Action is sent at time DMA-7002 or DMA-7004 is sent

Corrective Action Activities Required County should take corrective action to correct the case Train staff to prevent similar errors from happening Implement monitoring activity to ensure staff are appropriately implementing the training they received Provide followup training, if necessary Refer client responsible errors to county Program Integrity staff Keep records of training Report to DMA Quality Assurance via DMA-7003, Corrective Action Report corrective action taken on the case and information regarding training and referral to Program Integrity

Questions Contact Information: Shara.Britt@dhhs.nc.gov 919-814-0192