QUALITY ASSURANCE Angela Turner QA Coordinator

DAAS QA Program Redesign The QA department will continue : No service reports Tier changes Overlapping service Overlapping services The QA department will continue to refer to the Office of Medicaid Inspector General

Process Overpayment  DAAS QA will receive a report from DMS; we will verify billing and determine if a possible overbilling has occurred.  If overbilling has occurred, you will receive a Recoupment Letter explaining the recoupment process.

Reconsideration Process  The documentation will be reviewed to determine if it does or does not support billing.  If the provider disagrees with the decision, then the provider can ask for and appeal the decision (See provider manual for information on the appeal process.)

Corrective Action Plan  A corrective action plan is required for all findings.  It must also explain how the provider will prevent overlapping or overbilling from occurring in the future.  It must state who will be monitoring the process as well as the time frame it will be implemented.  The provider will receive a corrective action plan letter approving or denying the implemented process.

ALF Provider Billing Issues Increase or decrease in patient liability. Increase or decrease in patient liability. o This could cause a provider to overbill for services or not get the complete amount allocated for client. Tier level changes indicated on POC not being followed. Tier level changes indicated on POC not being followed. Provider billing when client is hospitalized causing overlapping services. Provider billing when client is hospitalized causing overlapping services. o ALF facilities cannot bill on day of admission, but are allowed to bill on day of discharge. DAAS QA receives a quarterly report of the overlapping services from DMS QA. (DAAS QA will now prepare quarterly reports) DAAS QA receives a quarterly report of the overlapping services from DMS QA. (DAAS QA will now prepare quarterly reports)

ALF- QA Issues DAAS QA receives weekly billing error worksheets from HP where providers have billed and it has been flagged for further determination. Most common triggers are: Client has tier change (up or down) in the middle of the month and provider billed at the wrong tier. Provider has billed before DAAS QA has received tier level. Provider billed for dates after the waiver has closed. Provider billed for dates before the effective date. NOTE: The effective date for the tier level is the day the client moves into facility. DAAS QA researches each claim and determines if the claim should be paid or denied.

Quarterly No Service Report No Service Reports are sent to DAAS QA on a quarterly basis by Division of Medical Services Quality Assurance. (DAAS QA will now be preparing quarterly report). The individual is required to receive services in order to be on the waiver and lack of billing could indicate the individual may not be receiving the care needed. DAAS QA contacts providers and researches to determine why the ALF facility has not been billing for the client, if the client is still a resident of the facility, or if there are any other issues that is preventing the facility from billing (ex. Problem with county office information.). DAAS QA also helps providers to resolve any issues or systems errors that may prevent billing for ALF clients.

ALF Provider Billing Issues Increase or decrease in patient liability. Increase or decrease in patient liability. o This could cause a provider to overbill for services or not get the complete amount allocated for client. Tier level changes indicated on POC not being followed. Tier level changes indicated on POC not being followed. Provider billing when client is hospitalized causing overlapping services. Provider billing when client is hospitalized causing overlapping services. o ALF facilities cannot bill on day of admission, but are allowed to bill on day of discharge. DAAS QA receives a quarterly report of the overlapping services from DMS QA. DAAS QA receives a quarterly report of the overlapping services from DMS QA.

Please read Medicaid Manual – all sections contain information you need to know in order to comply with regulations. It is your responsibility as a provider to follow the Medicaid regulations.

Contact Information Erin DeMarco R.N. QA Manager (501) Angela Turner QA Coordinator (501) Danita Kelley Administrative Specialist III (501) QA Address: QA Office Fax: (501) QA Mailing Address: Quality Assurance Division of Aging and Adult Services P.O. Box 1437, Slot S- 530 Little Rock, AR 72203