1. 03-23-05 October 2006 page 1 HCBS Waiver Overview Presented by EDS Waiver Audit Team

2. HCBS Waiver Billing Overview Presentation October 2006 page 2 Agenda Customers EDS Waiver Department Role Waiver Program Waiver Audit Process Documentation Standards Documentation Error Examples Case Management Audit Process Recoupment Appeals Questions

3. HCBS Waiver Billing Overview Presentation October 2006 page 3 The Office of Medicaid Policy and Planning (OMPP) The Division of Aging The Division of Disability and Rehabilitative Services The Bureau Of Developmental Disabilities Services The Bureau of Quality Improvement Services Customers

4. HCBS Waiver Billing Overview Presentation October 2006 page 4 Waiver Department Role To assist the OMPP in meeting federal assurances that funds are appropriately used: Members are eligible for services provided Services are appropriately provided according to the Center for Medicare and Medicaid Services (CMS)- approved waivers Provide education to the provider community through scheduled workshops, seminars, and training sessions Provide waiver audit services Report waiver audit findings to the OMPP, or other appropriate agencies

5. HCBS Waiver Billing Overview Presentation October 2006 page 5 Waiver Program In 1981 the federal government created Title XIX home and Community-Based Services Program. This act created exceptions to, or waived traditional Medicaid requirements. Medicaid Waiver programs are funded with both State and Federal dollars. All Indiana waiver programs have been initiated by the Indiana General Assembly and approved by the Centers for Medicare and Medicaid Services (CMS). Definition

6. HCBS Waiver Billing Overview Presentation October 2006 page 6 Waiver Programs Nursing Facility Level of Care Waivers: (Daily operations of these waivers are managed by the Division of Aging) Aged and Disabled (A&D) Traumatic Brain Injury (TBI) Assisted Living (AL) Intermediate Care Facilities for the Mentally Retarded (ICF/MR) Level of Care Waivers: (The Division of Disability and Rehabilitative Services manages daily operations for these waivers) Developmental Disabilities (DD) Autism (AUT) Support Services (SS) Types

7. HCBS Waiver Billing Overview Presentation October 2006 page 7 Waiver Program Hospital Level of Care Waiver: (The Division of Mental Health and Addictions manages daily operations of the contracts for this waiver) Children with Severe Emotional Disturbance (SED) Waiver Types

8. HCBS Waiver Billing Overview Presentation October 2006 page 8 Waiver Program Eligibility for all waiver programs requires the following: The member must meet the appropriate level of care criteria. The member must otherwise require institutionalization in the absence of the waiver or other home-based services. There are a limited number of slots for each waiver, and eligible individuals cannot receive services until a slot is available. The total Medicaid cost of serving the members on the waiver (waiver cost plus other Medicaid services) does not exceed the total cost to Medicaid for serving the members in an appropriate institutional setting. Member Eligibility

9. HCBS Waiver Billing Overview Presentation October 2006 page 9 When eligibility requirements are met, a case manager (CM), works with the client or the client’s representative, and other service providers to develop a Plan of Care (POC), which must be approved by the State and then identified on the Notice of Action (NOA). The NOA identifies all the services the client has been approved to receive, along with approved dollars, which is required for appropriate claims payment. Claims only pay if there are PA dollars available for the date of service submitted on the claim. Waiver Program Eligibility and Notice of Action

10. HCBS Waiver Billing Overview Presentation October 2006 page 10 Waiver Program In addition to the approved NOA, some services, such as home modifications require an approved Request for Authorization (RFA) before the service can be rendered. The CM must coordinate with BQIS to complete the RFA for any specialized medical equipment and supplies, vehicle modification, or environmental modification. Any RFA for specialized medical equipment and supplies, vehicle modification, installation or maintenance, continues to be approved by the Area Agency on Aging (AAA) designee, if the CM works for an AAA. When work is completed, or the product has been delivered, the provider must notify the case manager and the case manager MUST record in INsite. Request for Authorization

11. HCBS Waiver Billing Overview Presentation October 2006 page 11 Waiver Authorization BQIS then completes a Quality Assessment for that job by contacting the client to verify the job has been completed and that the member is satisfied. When BQIS completes their certification they enter the completion date into INsite. The case manager is responsible for signing and providing the approved RFA to the service provider. Providers may NOT bill until they have received an approved and signed RFA. The approved signed RFA form does not have to accompany the billing, but must be completed and in the INsite system before billing takes place. Request for Authorization

12. HCBS Waiver Billing Overview Presentation October 2006 page 12 Audit Process To educate and assist Home and Community Based Services (HCBS) Waiver providers To achieve Indiana Health Coverage Programs (IHCP) compliance in documentation and billing To recover funds inappropriately billed to the IHCP Purpose

13. HCBS Waiver Billing Overview Presentation October 2006 page 13 Audit Process Provider Selection Process Providers are randomly selected from list of actively billing providers for a specified audit review time frame. Every enrolled provider will eventually receive an initial audit Member Selection Process Members are chosen from provider’s client base. Entrance Conference Initial meeting with provider and auditors before the audit commences to introduce auditors and audit process. Stages

14. HCBS Waiver Billing Overview Presentation October 2006 page 14 Audit Process Review Process Requested documentation is reviewed to verify submitted claim information was accurate. Home Visits The purpose of home visits is to validate the member’s level of care, to verify the appropriateness of services, and to initiate referrals for quality issues as needed. Exit Conference The purpose of the exit conference is to share audit findings and provide education. No financial recoupment information is shared at this time, any recoupment must be verified by a financial analyst and will be sent to the provider within 45 days of the audit exit. Stages

15. HCBS Waiver Billing Overview Presentation October 2006 page 15 Documentation Standards Documentation standards and requirements are published in every CMS-approved waiver. The provider must know and follow established documentation standards and requirements. Documentation standards and requirements are dependent on the service provided and the waiver level of care. Documentation standards and requirements are published in IHCP provider bulletins.

16. HCBS Waiver Billing Overview Presentation October 2006 page 16 Documentation standards were published in IHCP provider bulletin BT200371 on December 19, 2003, for the Nursing Facility Level of Care Waivers. Documentation standards were published in IHCP provider bulletin BT200305 on January 1, 2003, for the ICF/MR Level of Care Waivers. –Dates of service as documented must match the dates of service billed –Documentation must support the units of service billed The following publications are the authority for audit exceptions: –405 IAC 1-1-4, Denial of claim payment –405 IAC 1-15, Overpayments made to providers – recovery –405 IAC 1-1-6, Sanctions against providers Documentation Standards

17. HCBS Waiver Billing Overview Presentation October 2006 page 17 Documentation Standards Documentation standards for Nursing Facility Level of Care Waivers were published in IHCP provider bulletin BT200371 on December 19, 2003. The standards include the following: –Dates of service as documented must match the dates of service billed –Documentation must support the units of service billed Standards for A&D, TBI, and AL Waivers

18. HCBS Waiver Billing Overview Presentation October 2006 page 18 Documentation Standards Current documentation standards became effective November 1, 2005, for the ICF/MR Level of Care Waivers. This information was published in DDARS Bulletin 80, released September 15, 2005. Annual Plan for DD, AU, and SS Waivers

19. HCBS Waiver Billing Overview Presentation October 2006 page 19 Documentation Standards The services authorized on the NOA must: Meet the needs of the member as identified on the ISP or POC Be addressed in the Individualized Support Plan (required for DD, SS, and AUT) or the POC Be authorized and provided in accordance with the definition and parameters of the service NOA Services

20. HCBS Waiver Billing Overview Presentation October 2006 page 20 No services should be provided unless they are authorized by an approved Notice of Action (NOA) Providers must have copies of the following: –Approved NOA –NOA supplemental information Documentation Standards NOA Services

21. HCBS Waiver Billing Overview Presentation October 2006 page 21 Documentation Errors The top five documentation errors: 1.Documentation did not support units billed 2.There was no documentation to review for units billed 3.Altered documentation 4.Documentation contained missing, incomplete or invalid signatures 5.Documentation of respite lacked required elements

22. HCBS Waiver Billing Overview Presentation October 2006 page 22 Documentation Errors All documentation errors must be corrected using the following universally accepted method: Draw a line through the entry (in ink) Do not obliterate the word Enter the correct information Initial and date the change See IHCP provider bulletins BT200305 and BT200371 for more information. Altered Documentation

23. HCBS Waiver Billing Overview Presentation October 2006 page 23 All documentation must contain the following: An original, legible signature for each date of service or member encounter A minimum of first initial, last name, and title (if required) No printed names No signature stamps See IHCP provider bulletins BT200371 and BT200305 and provider monthly newsletter NL200409 for more information. Documentation Contained Missing, Incomplete, Or Invalid Signatures Documentation Errors

24. HCBS Waiver Billing Overview Presentation October 2006 page 24 Documentation must include all three of the following elements: 1.Reason for the respite 2.Location where the service was rendered 3.Type of respite rendered See IHCP provider bulletin BT200371, published December 19, 2003, BT 200315, published February 21, 2003, provider monthly newsletter NL200409, and 460 IAC 6-3-49 for more information. Documentation of Respite Lacked Required Elements Documentation Errors

25. HCBS Waiver Billing Overview Presentation October 2006 page 25 Most often, case manager audits consist of desk audits, but may be on-site as directed by the OMPP. Audits may be initiated and prioritized as a result of referrals or random selection. Providers are given an initial audit subject to limited recoupment guidelines, with the exception of referral audits which are subject to full recoupment guidelines. Subsequent audits are subject to full recoupment guidelines. The EDS case manager audit team reviews provider documentation that supports claims paid during a specified audit time frame, for a specified sample of case managers and member populations. Case Manager Audit Process

26. HCBS Waiver Billing Overview Presentation October 2006 page 26 Case Manager Audit Process Provider selection process Member selection process Provider notification and record request process Desk review process Provider telephone exit conference Provider findings mailed (within 45 business days of audit completion) Stages

27. HCBS Waiver Billing Overview Presentation October 2006 page 27 Claims inappropriately billed to the IHCP are subject to recoupment (per IHCP provider bulletin BT200412 issued June, 2004). Recoupment was initiated in June 2004: ―Interest is recovered on all overpayments identified in an audit ―Appeals are conducted in accordance with 405 IAC 1- 1.5 and must be filed within 60 days of receipt of the findings letter The following publications are the authority for exceptions (recoupment): –405 IAC 1-1-4, Denial of claim payment –405 IAC 1-15, Overpayments made to providers – recovery –405 IAC 1-1-6, Sanctions against providers Recoupment

28. HCBS Waiver Billing Overview Presentation October 2006 page 28 Appeals All audit findings are subject to provider appeal. Appeals are conducted in accordance with 405 IAC 1-1.5. Appeals must be filed within 60 calendar days of receipt of the audit findings letter. EDS mediates the appeal using the following process: –Provider sends Statement of Issues with audit findings. –EDS reviews the Statement of Issues and another independent review of supportive documentation, and returns a decision to rescind, modify, or uphold the original audit findings. EDS issues the reconsideration findings to the provider, and the provider may withdraw the appeal or continue with the appeal request. Then, the appeal goes to an administrative law judge (ALJ).

29. HCBS Waiver Billing Overview Presentation October 2006 page 29 Audit Supporting Criteria 460 IAC 6 – Final Rule for Supported Living Services and Supports 460 IAC 7 – Standards and Requirements for Individualized Support Plans IHCP/OMPP bulletins, banner pages, and newsletters BDDS and BQIS bulletins and memorandums Division of Aging Bulletins DDRS Bulletins DDRS newsletter Indiana Medicaid HCBS Waiver Provider Manual IHCP Provider Manual IHCP E-mail Notifications Program

30. HCBS Waiver Billing Overview Presentation October 2006 page 30 Questions

31. 03-23-05 October 2006 page 31 EDS 950 N. Meridian St., Suite 1150 Indianapolis, IN 46204 Presentation by EDS Waiver Audit Team EDS and the EDS logo are registered trademarks of Electronic Data Systems Corporation. EDS is an equal opportunity employer and values the diversity of its people. © 2005 Electronic Data Systems Corporation. All rights reserved.