overview of the audit process - wisconsin department of ...(pg. 69) added step 2 (about confirming...
TRANSCRIPT
DEPARTMENT OF HEALTH SERVICES
Office of the Inspector General
Overview of the Audit Process
Volume
1
D E P A R T M E N T O F H E A L T H S E R V I C E S
Office of the Inspector General
Department of Health Services 1 West Wilson Street Madison, WI 53701
Phone 608.266.2522 • Fax 608.267.3380
Revision History New Revision Date
(Previous revision dates need to be placed on the OIG L: drive)
Revision Page Number(s)
What was changed & reason for change (if applicable)
Revisions Completed By
Revisions Accepted by (OIG supervisor)
08/01/2016 All Creation of document Kari Engelke, Justin Lawfer, Kelly Wilson
Kari Engelke, Kelly Wilson
12/21/2017 Various Added template for requesting equipment for onsite records collection (Pgs. 12 – 13).
Per 10/18/17 training: Updated Closing the Audit steps re: new Audit Summary Letter and routing process (Pgs. 29-30).
Per 10/18/17 training: Updated Fraud Referrals steps re: new referral preparation process and UPIC referrals (Pgs. 32-35; 39 - 40).
MARS and PARS management team; Justin Lawfer
MARS and PARS management team
03/23/2018 2 – 23, 55-57
Added information about MARS audit process (all pages).
Updated “Audit Selection” section (Pg. 9).
Added “New Documentation for SURS Case Tracker” section (Pgs. 18-19).
Updated information regarded Amended Preliminary Finding and Notice of Intent to Recover (NIR) letters (Pgs. 20-23).
Added Narrative Findings example document as Appendix B (Pgs. 55-57)
MARS/PARS Process Alignment Workgroup
MARS and PARS management team
6/14/2018 24 - 32 Updated “Obtaining Records” and “Preparing for Onsite Records Collection” sections (Pgs. 24 – 29)
Added “Onsite Records Collection” section (Pgs. 29 – 32)
MARS and PARS Process Alignment Workgroup; Justin Lawfer
MARS and PARS management team
7/16/2018 33 - 85 Added or made revisions to the following sections (Pgs. 33 – 85): o Preparing for the
Audit o Conducting the
MARS and PARS Process Alignment Workgroup; Justin Lawfer
MARS and PARS management team
Audit o Entering Audit
Findings o Generating Audit
Letters and Reports
o Saving Audit Documents to Audit File (MARS)
o Routing Audit Documents for Peer Review and Management Approval
o Peer Review o Document
Approval in SURS
o Rebuttal Documentation
o Undeliverable NIR/Provider Refuses NIR
o Recoupments (Financial Transaction Forms)
Removed “No Findings” and “Preliminary Findings” sections (language has been incorporated elsewhere in document) (Pgs. 34 - 35)
Moved “Exit Conferences with Providers” section to after “Document Approval in SURS” section (Pgs. 79 – 82)
08/22/2018 85 - 93 Updated language in “Provider Communication” and “Provider Appeals” section (Pgs. 85 – 89)
Added “Administrative Hearings” subsection and “Preparing to Testify” subsection (Pgs. 90 – 93)
MARS and PARS Process Alignment Workgroup; Justin Lawfer
MARS and PARS management team
09/24/2018 95 - 96 Added step about completing RECORD LOCATION section of Audit Summary Letter.
Justin Lawfer MARS and PARS management team
11/28/2018 Various Added “Completing the Audit Plan” section (Pg. 39)
Removed text that is now in OIG TPL Reference Guide (Pg. 48)
Justin Lawfer MARS and PARS management team
Added “Providers Wanting to Return Overpayments” section (Pg. 69)
Added Step 2 (about confirming audit documentation has been uploaded to case) to the “Closing the Audit” section (Pg. 80)
Updated Step 15 (regarding materials going to the records center) of the “Closing the Audit” section (Pg. 83)
Added “Paper Record Destruction” instructions per RDA-00404 (Pgs. 84-85)
Added Appendix C. Provider Payment at Prelim/Amended Prelim Scenarios (pgs. 100 – 105)
Table of Contents
Chapter 1. Overview of the Office of the Inspector
General .................................................................................. 1
Audit Authority ................................................................................. 1
Chapter 2. Audit Information................................................... 2
Categories of MARS Audit Types ................................................... 2
Categories of PARS Audit Types .................................................... 6
Audit Selection ................................................................................ 9
New Audit Ideas .............................................................................. 9
Narrative Findings Structure ................................................................... 10
Audit Scheduling ........................................................................... 12
Types of Audit Cases .................................................................... 12
Audit Documentation ..................................................................... 13
Location of Audit Documentation ............................................................ 17
New Documentation for SURS Case Tracker ........................................ 18
Audit Letters .................................................................................. 20
Chapter 3. Overview of the Audit Process ........................... 24
Obtaining Records ........................................................................ 24
Preparing for Onsite Records Collection ....................................... 25
Onsite Records Collection ............................................................. 29
Preparing for the Audit .................................................................. 33
Research ................................................................................................. 34
Max Fee Schedules ................................................................................ 36
Completing the Audit Plan ............................................................. 39
Conducting the Audit ..................................................................... 40
Complaint Reports (MARS) .................................................................... 40
Prior Authorizations................................................................................. 41
Provider Certification............................................................................... 46
Recipient Name Change ......................................................................... 47
Third-Party Liability ................................................................................. 48
Third-Party Liability Query ...................................................................... 49
Claim Adjustments .................................................................................. 53
Entering Audit Findings ................................................................. 57
Generating Audit Letters and Reports ........................................... 57
Saving Audit Documents to Audit File (MARS) ............................. 57
Routing Audit Documents for Peer Review and Management
Approval ........................................................................................ 58
Peer Review .................................................................................. 61
Document Approval in SURS ........................................................ 65
Exit Conferences with Providers ................................................... 65
Preparing for the Exit Conference .......................................................... 65
Conducting the Exit Conference ............................................................. 66
Providers Wanting to Return Overpayments ................................. 69
Rebuttal Documentation ................................................................ 69
Undeliverable NIR/Provider Refuses NIR ..................................... 70
Recoupments (Financial Transaction Forms) ............................... 71
Provider Communication ............................................................... 71
Provider Appeals ........................................................................... 73
Administrative Hearings .......................................................................... 76
Preparing to Testify ................................................................................. 78
Closing the Audit ........................................................................... 80
Paper Record Destruction ............................................................. 84
Chapter 4. Fraud Referrals .................................................... 86
Medicaid Fraud Control and Elder Abuse Unit (MFCEAU) ............ 86
Submitting Additional Exhibits ....................................................... 90
Implementation of Medicaid Payment Suspensions ...................... 90
Unified Program Integrity Contractor (UPIC) ................................. 93
Appendix A: Acronyms .......................................................... 95
Appendix B: Narrative Findings Example .............................. 97
Appendix C: Provider Payment at Prelim/Amended Prelim Scenarios ............................................................................. 100
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The purpose of this guide is to provide an overview of the OIG, explain the audit process, and to provide helpful information to employees.
Overview of the Office of the Inspector General (OIG) The Office of the Inspector General (OIG), in support of the Department of Health Services’ (DHS) commitment to be an effective steward of the public resources the DHS is entrusted to manage, has department-wide responsibilities for auditing the use of department funds. The OIG, which reports directly to the DHS Secretary, conducts audits of providers who receive department funds, performs internal audits of department programs and operations, and investigates allegations of fraud, waste, or abuse of DHS resources by contractors, providers and recipients. The OIG is responsible for working with DHS program divisions and partners to develop policies and practices to prevent fraud, waste and abuse.
The OIG is made up of five sections: Program Audit and Review (PAR), Medical Audit and Review (MAR), Internal Audit, Data Analytics, and Fraud Investigation, Recovery and Enforcement (FIRE). This guide covers the process that the Program Audit and Review section uses when conducting Medicaid audits.
Audit Authority
OIG has the authority to conduct Medicaid audits based on the statutes written in the Wisconsin Administrative Code sections DHS 101-108. All providers agree to be subject to audit if they want to be a certified Medicaid provider, as stated in Section 2 item e. of the Wisconsin Medicaid Provider Agreement and Acknowledgement of Terms of Participation. OIG follows Government Auditing Standards (GAS). In addition, OIG follows the rules and requirements written in the provider handbooks and provider updates. OIG will recoup funds from providers who fail to comply with the rules and regulations written in the provider handbooks, updates, Wisconsin Administrative Code, and Federal regulations.
Chapter
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Audit Information
All Medicaid providers are subject to audit at any time. The “Categories of MARS Audit Types” and “Categories of PARS Audit Types” sections introduce some of the most common and consistent provider and audit types that MARS and PARS reviews. The focus for each section may change from year to year as agency priorities shift, and with the annual work plan. These are not all-inclusive lists as new audits are started each year.
Categories of MARS Audit Types
Chiropractors o Wisconsin Medicaid covers chiropractic services for spell-of-illness treatment of
acute spinal subluxations. Treatment of sprains, strains, and chronic conditions is not covered. The first 20 visits per spell of illness do not require prior authorization, but treatment beyond those 20 visits is not covered without prior authorization. Partially because of this, chiropractic documentation has specific requirements, including tracking the number of visits per spell of illness. Without meeting these documentation requirements, services are not covered.
Dentists o Dental services are provided through Wisconsin Medicaid for both children and
adults. Certain codes, such as cleaning and x-rays, are covered a limited number of times per year. Other codes include multiple services bundled into one code. If these services are billed separately, this is considered “unbundling,” and is not covered. Medical necessity, especially of anesthesia provided in conjunction with dental care, is not always established in a provider’s documentation.
Home Health Agencies o Home health agencies provide services in the member’s home. Home health services
focus on skilled nursing services for a specific purpose, such as assessment, wound care, ostomy care, catheterization, or feeding tube insertion and/or feeding. If home health services are required for more than 8 hours in a 24 hour period, the member may enroll in private duty nursing (PDN) services.
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o Hospices provide services to those who are terminally ill, as well as supportive care
to their family members and caretakers. There are four categories of hospice services, routine care, continuous care, inpatient respite care and general inpatient care. Hospice care can be provided in a facility or in the member’s home. Eligibility for services requires certification, or recertification by a physician that the member has a terminal illness, that reduces their life expectancy to six months or less, and the member signing the Election of Hospice benefit. The attending physician along with the interdisciplinary care team, establish a written plan of care for the member before hospice services are provided. Some findings noted in hospice audits include lack of documentation of written election of hospice benefit, informed consent, insufficient documentation of the services provided, not following the plan of care (POC), the interdisciplinary team (IDT) not reviewing the POC every 15 days, and not meeting the program or certification requirements.
Laboratory/Pathology o Laboratory and pathology services evaluate specimens (e.g., blood, body fluid, tissue)
obtained from patients to provide information to the treating physician. Laboratory/pathology audits verify that the services are in compliance with documentation and billing requirements; the services are medically necessary; the services have a valid physician order; and the provider is certified to perform the test or is using a waived test.
Mental Health Providers o Mental health providers offer psychotherapy and medication management to
Wisconsin Medicaid members. These services can be provided either in person or via telehealth by psychiatrists, psychologists, nurse practitioners with advanced mental health certifications, and social workers. Consents are required for many mental health services to be covered by Wisconsin Medicaid. Psychotherapy can be provided individually, for families, and as group therapy. Upcoding services, where a more complex service was billed than was documented, is also seen in this provider type.
Certificate of Need (CON) Audits
Certificate of Need (CON) audits are performed for selected providers and including selected members under the age of 21 who are admitted to an institution for mental disease (IMD) hospital and are required to have a completed CON document in their medical record. Certification shall be made for a member when the person is admitted to a facility or program by an independent team that includes a physician. The team shall have competence in diagnosis and treatment of mental illness, preferably in child psychology, and have knowledge of the member’s situation. For emergency admissions, the certification shall be made by the team within 14 days after admission. The documentation is missing a CON, the CON documentation is incomplete, and the CON is invalid are findings seen in these audits.
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Nurses in Independent Practice
o Nurses in independent practice (NIP) provide PDN services to members. These services are available to members who require greater than 8 hours per day of skilled nursing services, and frequently involve those who require 24 hour nursing care. Several nurses can work for one member, but no NIP can provide more than 12 hours of care in a 24 hour period, and no more than 60 hours in one calendar week. They are also required to have a minimum of “eight continuous and uninterrupted hours off duty in any 24-hour period during which he or she performs PDN and/or PDN-Vent services that are reimbursed by Wisconsin Medicaid” [DHS 107.113 (5) (d), and DHS 107.12 (4) (f) and (g)]. Time units are reported in rounded hours, and each claim should have a shift modifier included.
Personal Care Agencies o Personal care agencies provide assistance with activities of daily living to Medicaid
members in their own homes. The work is performed by personal care workers (PCWs), who are unlicensed personnel trained and supervised by a Registered Nurse. No certification or training outside of that provided by the agency is required to act as a PCW. A limited amount of time is allotted to assist with incidental activities of daily living (IADLs), such as shopping, meal preparation, and light cleaning, in addition to time allotted for ADL assistance. Time units are reported in rounded increments of 15 minutes.
Physicians and Midlevel Providers (Nurse Practitioner, Physician Assistant) o Physicians and Midlevel Providers audits focus on evaluation & management visit
upcoding, in which a provider’s office bills a more complex visit than what was documented resulting in higher reimbursement. In addition to evaluation & management services physicians, nurse practitioners, and physician assistants are providing multiple categories of service to their patients, including laboratory, podiatry, physical therapy, durable medical equipment, and procedures. This increases the complexity of audits, and frequently requires citing multiple sections of the ForwardHealth handbook in findings.
Anesthesia
Anesthesia audits are focused on compliance to documentation and billing requirements. Anesthesiologists are limited in the number of cases they can direct at one time and be eligible for reimbursement. Historically this has been the focus of these audits; however, it is difficult to monitor, as the limited number of cases includes all patients, not just those who receive Medicaid.
Obstetric
The obstetrical services audit consists of a review of the member’s clinical and hospital ante-partum, delivery, and post-partum records to ensure compliance with Medicaid documentation and billing requirements for reimbursement. OB providers may bill the global code for obstetric services composed of antepartum, delivery and a post-delivery hospital visit, and at least one post-partum visit, as well as any
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evaluation and management services unrelated to the pregnancy. Common audit findings for OB services include lack of documentation, incomplete documentation of the services provided, incorrect modifier, and unbundled procedure (billing the global code when one or more of the required visits is not performed by the provider).
Limited Scope/Focused Audits o Certain services, such as personal care and private skilled nursing services, are not
covered by Wisconsin Medicaid while a member is in the hospital or other institution. Limited scope and focused audits compare claims data from these institutions and other provider types to determine whether a service is covered based on admission and discharge dates. These audits can also look for other codes that are billed on the same date for the same member, such as laboratory codes, to determine if one is not covered. No provider documentation is required or requested for these audits prior to preliminary findings being issued.
Therapy o Physical therapy, occupational therapy, and speech therapy audits focus on services
provided to infants, children and adults. All therapy services must be medically necessary, and provided under a plan of care (POC), established by the ordering physician and rendering therapist. The POC needs to include the type, amount, frequency, and duration of therapy services, and be reviewed by the physician at least every 90 days. Specific therapies can be provided by a certified physical therapy assistant, and a certified occupational therapy assistant, under the direct and immediate supervision of a physical therapist, and occupational therapist respectively. Common therapy audit findings include lack of a signed physician’s order, no therapy POC, lack of direct supervision of therapy aides, the rendering provider listed on the claim is not the therapist performing the therapy, billing in excess of the services provided, and billing for services that were not rendered.
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Categories of PARS Audit Types The corresponding audit guides or reference materials for each audit type are located at L: > Oig Ma > Auditor > Audit Procedures.
Comprehensive Community Services (CCS) Audits o CCS programs provide and arrange for the provision of psychosocial rehabilitation
services. Psychosocial rehabilitation services are defined as medical and remedial services and supportive activities provided to or arranged for a consumer by a comprehensive community services program authorized by a mental health professional to assist individuals with mental disorders or substance-use disorders to achieve the individual's highest possible level of independent functioning, stability and independence and to facilitate recovery.
Date of Death Audit o The purpose of this audit is to identify payments made to providers and Health
Maintenance Organizations (HMOs) for services dated after members’ Date of Death (DOD).
DME (Durable Medical Equipment)/DMS (Disposable Medical Supply) Audits o Examples: Breast Pumps, Mickey Buttons, Hospital Beds
Electronic Health Records (EHR) Audits o OIG audits incentive payments made to eligible professionals and hospitals as they adopt,
implement, upgrade or demonstrate meaningful use of certified EHR technology. Note: EHR audit guides are located at L: > Oig Ma > Auditor > EHR > HIT EHR Audit Procedure Manuals.
Federally Qualified Health Centers (FQHC) Audits o These agencies must serve either a federal designated health professional shortage area,
medically underserved area, or medically underserved population, or be a tribal clinic. To receive 100% reimbursement of its Medicaid costs as an FQHC, the clinic must submit an annual FQHC Cost Report to the OIG; the OIG audit then establishes a rate based on the FQHC’s costs and total encounters and determines the appropriate reimbursement amount.
HMO Audits o Examples: Capitation Payments, Kick Payments, Vent, and Program Integrity Reviews
Capitation payment audits determine if capitation payments were made on stillborn babies.
Kick payments are supplementary payments to a HMO for providing delivery services. The Kick payment is in addition to the HMO cap payments. OIG audits the HMOs’ Kick payment data against the HMO submitted encounter data to determine if Kick payments were made appropriately.
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The ventilator (“vent”) audits determines if an HMO received any erroneous enhanced funding for ventilator-dependent members who require total respiratory support or who died while on respiratory support.
Program Integrity Reviews determine compliance with the program integrity components of the HMO contract and the Centers for Medicare and Medicaid Services (CMS) Managed Care Final Rule (refer to Federal Register Volume 81, Number 88).
IRIS (Include, Respect, I Self-Direct) o Participants enrolled in IRIS self-direct their goods and services. The providers of
approved supports and services are then paid through the IRIS fiscal employer agent (FEA). Fiscal employer agents are responsible for processing payroll, managing federal and state tax withholdings, ensuring provider qualifications, and reporting obligations related to participant-hired workers. FEAs also assist with other employer responsibilities. OIG audits FEAs to ensure compliance with IRIS program requirements.
Lab Audits o Examples:
Global vs. technical/professional components (this is a bulk audit that is done annually)
Quantity restrictions
Pharmacy Audits o Examples:
Combo audit (this is a comprehensive audit that also reviews excessive quantity and duplicate billing of drugs)
Compounds
New pharmacies
STAT-PA (Specialized Transmission Approval Technology-Prior Authorization)
Prenatal Care Coordination (PNCC) / Child Care Coordination (CCC) Audits o The Prenatal Care Coordination Services (PNCC) program was created to help Medicaid
eligible pregnant women gain access to medical, social, educational, and other services related to the recipient’s pregnancy in the hopes of improving the birth outcomes of women who are at high risk for poor birth outcomes.
o The Child Care Coordination Services (CCC) program was created to extend PNCC services to qualified recipients in Milwaukee County and the city of Racine. Recipients in Milwaukee County qualify for CCC services until the child’s seventh birthday. Recipients in the city of Racine qualify for CCC services until the child’s second birthday. The CCC program helps Medicaid eligible recipients gain access to medical, social, educational, vocational, and other services in hopes of promoting positive parenting, improving child health outcomes, and preventing child abuse and neglect.
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Rural Health Centers (RHC) Audits o An RHC is a primary care clinic serving a rural, underserved area and is eligible for
cost-based reimbursement from Wisconsin Medicaid for specific services, known as RHC services.
o Clinics are required to file yearly Cost Reports showing Medicaid encounter volume, reimbursements, and possibly operational costs, in order to receive reimbursement from Wisconsin Medicaid. The audit is performed as an independent verification check on the validity of costs, encounters and related reimbursements received.
SMV Audits o A broker manages the SMV companies. OIG only audits SMV claims from nursing
homes, which are not included in the brokerage contract.
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Audit Selection
OIG selects audit areas and/or providers for audit using several different measures and methods that include, but are not limited to:
Complaints - Sometimes an audit will be conducted based on a complaint that is received from MFCEAU (Medicaid Fraud Control and Elder Abuse Unit), outside state agencies, law enforcement agencies, recipients, providers and state staff, and through the fraud hotline. Each complaint is logged into SURS Case Tracker where it is reviewed by management to determine whether an audit should be opened or other action taken.
New Medicaid provider review - OIG may monitor claims for new providers on an ongoing basis to determine when or if an audit is needed.
Outlier reports – These identify providers who exhibit billing behaviors or patterns that are different from other providers with the same Provider Type. This includes, but is not limited to:
Weekly over $100,000 report - OIG monitors providers who receive payments over $100,000 in a given week.
Special requests from the Centers for Medicare and Medicaid Services (CMS), Wisconsin legislators, the Secretary’s Office, etc.
Targeted Queries (TQs) - OIG has prebuilt targeted queries that pull claims for all providers who meet specified criteria.
The Data Analytics unit also assists in developing audits by using its tools and expertise to analyze claims data and identify aberrant billing practices.
New Audit Ideas PARS: Auditors are encouraged to research and propose new audit ideas using the Audit Proposal Template form located at L: > Oig Ma > Auditor > Audit Procedures. This form will be routed through management to determine the feasibility of pursuing the audit. For Provider Impact, auditors will use Business Objects or submit a request to the Data Analytics Section to obtain this information.
Approved audit proposals are saved to L: > Oig Ma > Auditor > PARS Audit Proposals. For new audits, auditors will be responsible for creating appropriate audit documentation such as Audit Plans, Narrative Finding Reports, and Technical Assistance Reports. Auditors should refer to pre-existing audit documentation in the SURS Documentation panel to learn how these documents are structured (for Narrative Finding Reports, auditors can also refer to the “Narrative Findings Structure” instructions below). The auditors will then submit these documents to the Financial Program Supervisors for review. If approved, these documents will be added to the SURS Documentation panel.
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Appendix B of this document includes an example of a Narrative Findings document.
Note: A Narrative Finding may also be called a Finding of Fact or a Record of an Audit Finding.
NARRATIVE FINDINGS STRUCTURE
All Narrative Findings should include the following sections.
1. Finding
Indicate the finding type (i.e. Non-covered Services) and what that finding type means. This language should be the same for all Narrative Findings.
2. Statement of Condition
Include a brief description of what claims/services were reviewed in the audit. This will be adjusted depending on the audit.
3. Effect
Include a description of the result of the audit/Statement of Condition. This language should be the same for all Narrative Findings.
4. Recommendation
Indicate what action(s) the provider should take in order to prevent similar audit findings from occurring again, and indicate what action(s) Medicaid should take as a result of the audit findings. The recommendation will consist of two paragraphs, which should read as:
It is recommended that the provider review the Wisconsin Administrative Code and the ForwardHealth Online Handbook and updates for provider documentation and billing procedures.
Lastly, it is recommended that Medicaid seek repayment of claims paid to the provider by Medicaid that could not be adequately supported by existing documentation.
5. Criteria
This language should be the same for all Narrative Findings.
6. Pertinent Rules and Regulations
Arrange supporting rules and regulations in the following order: a. Federal Regulations (if applicable) b. Wisconsin Administrative Code c. Wisconsin Medicaid Handbook (for PARS audits)
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Federal Regulations
Each section and subsection of a Federal Regulation should be on a separate line that is indented one tab more than the preceding line. When citing Federal Regulations, the title should be formatted as: Name of the regulation or Federal act / Section title / [Title number / Abbreviated name of the source / Section number] Auditors are responsible for including Federal Regulations that were in effect during the scope of the audit. Federal Regulations that were not in effect should not be included. Wisconsin Administrative Code Wisconsin Administrative Code should be listed in numerical order. Each section and subsection of the Admin Code should be on a separate line that is indented one tab more than the preceding line. Words should be formatted (i.e. bold, italicized) in the manner they are formatted in the Admin Code. Most Admin Code citations will come from Chapters DHS 101-109 Medical Assistance. If citations are used from other chapters (i.e. Pharmacy Examining Board), keep the citations organized by chapter.
Wisconsin Medicaid Handbook MARS: MARS’ Narrative Findings do not include specific Wisconsin Medicaid Handbook citations, as these citations are listed in the comments on their audit reports. PARS: List the specific Wisconsin Medicaid Handbook being cited. Wisconsin Medicaid Handbook entries should be listed in the order they appear in the corresponding handbook. Each subtitle should be formatted as: Handbook section: Chapter – Subchapter/Topic Auditors are responsible for including Wisconsin Medicaid Handbook citations that were in effect during the scope of the audit. Handbook citations that were not in effect should not be included. Refer to the “Preparing for the Audit” section for instructions on how to locate Wisconsin Medicaid Handbooks.
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Audit Scheduling
MARS: The Nursing Supervisors and Section Chief meet weekly to review fraud hotline, web portal, and internal complaints, and meet bi-monthly with the Data Analytics team. Once per month the Nursing Supervisors and Section Chief meet to discuss the audit schedules for the upcoming months. The Section Chief routes the audit schedule to the Deputy Inspector General 45 days prior to the month when the audits will be assigned to audit staff (i.e. the March audit schedule is routed by January 15th). The Nursing Supervisors email the approved schedule to audit staff approximately two weeks prior to the month the audits will be assigned (i.e. the March audit schedule is emailed in February); this allows audit staff time to schedule onsite record collections for their audits. PARS: Twice a month the Financial Program Supervisors, Section Chief, the Data Analytics team, and Advanced Auditor meet to discuss the audit schedules for the upcoming months. Prior to the scheduling meetings, the Data Analytics team researches data, selects claims for audit (based on feedback from management), and opens cases. Admin staff and the supervisors create Record Request letters (see “Audit Letters” section) to mail to providers. Admin staff will log providers’ records as they are received and notify the supervisors as to which cases have records available for audit. The supervisors will use this information to determine which cases can be assigned to auditors. Supervisors create the schedule and bring it to the monthly meetings for discussion.
At the audit scheduling meeting, the Section Chief may bring complaints for the group to review and discuss. Other audit ideas are also discussed at the scheduling meeting.
The supervisors route the audit schedules to upper management for approval. If the schedules are approved, the schedules are emailed to audit staff at the beginning of each month showing audits assigned for the upcoming month.
Types of Audit Cases A. Single Provider Audits- In a single provider audit, auditors will audit one provider for the
audit area. Auditors will conduct a comprehensive or focused review of the provider’s claims and records to ensure their documentation is in compliance with Medicaid regulations and guidelines.
B. Bulk Audits- In a bulk audit, auditors will audit many providers for the same audit issue. Each of the providers in the bulk audit will be assigned their own individual case number; however, they are all part of the same bulk audit number (this bulk audit number begins with a ‘B’).
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Audit Documentation
Auditors will maintain an audit file that includes the documents described later in this section.
MARS: Audit File Setup and Organization
I. Audit File Organization
When a MARS case is set up and assigned to an auditor, the auditor will create a file folder in the appropriate audit program folder on the shared drive, L: > Oig Ma > Audit Programs. Examples: PCW, HomeHLTH, PDN
II. Organization and Naming of File Folders
Audit file folders are stored in L: > Oig Ma > Audit Programs drive for shared access for auditors and management. When the provider is the name of an agency or organization, the file folder name will begin with the provider name followed by the SUR case number. Example: Hope Family Services 201299991 When the provider is an individual person (e.g., nurse in independent practice), the file folder name will begin with the last name of the individual person, a comma, the first name of the person, and lastly the case number. Example: Doe, Jane 201588413
III. Subfolders
Subfolders will be set up to describe the typical stages of the audit or other activities associated with the case. Certain folders are required and others are optional based on the activities of the case. Required Subfolders: Prelim, NIR, Phone Records, Peer Review Examples of Optional: On-site, In-home Evaluations, Scanned Documents, MFCU Referral, Appeal, Promissory Note
IV. Other Best Practices
When saving reports and letters, do not change the name assigned by SUR. Save the comment grid used during the preliminary findings phase within the Preliminary subfolder. For consistency, use the same comment grid for all phases of the audit.
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When the case is closed, move the audit case file to ZZZClosedAudits folder located in L: > Oig Ma > Audit Programs.
Audit Documents and Descriptions Below is a description of documents found in the audit file kept by the auditor.
Audit Plan- Audit plans are completed for each audit and are uploaded to the audit's case number in SURS Case Tracker. Audit plans can be found in the Documentation panel in SURS Case Tracker. Audit plans describe the background and purpose behind the audit, the objectives of an audit, audit scope, sampling criteria, and the steps in completing the audit.
o MARS has two audit plans: one for desk audits and one for onsite audits.
Auditors will use information from the Audit Details panel and the Audit List Report to fill out the fields on the first page (Provider Audited, Provider Number, Case Number, Date of Audit, and Auditor(s) Assigned) and any [x] values throughout the audit plan.
o PARS has various audit plans, depending on the type of audit. Auditors will use information from the monthly audit schedule to fill out the
fields on the first page (Provider Audited, Provider Number, Case Number, Date of Audit, and Auditor(s) Assigned) and the highlighted entries throughout the audit plan. For bulk audits, auditors can enter “Various” in the Provider Audited and Provider Number fields, and enter the Bulk ID in the Case Number field.
MARS audit plans include language regarding onsite records collection. For PARS audits, an entry for onsite records collection may need to be added to the Audit Methodology section, if applicable.
Example:
B. On-site Record Collection:
-- Make copies of the appropriate condom prescriptions and/or dispensing logs for the recipients included in the audit.
Audit letters- Letters generated in SURS which are mailed to the provider (Record Request letter, No Findings letter, Preliminary Findings letter, Amended Preliminary Findings letter, NIR letter, etc.).
Audit Reports- Reports generated and mailed to the providers along with the audit letters. These include:
o Preliminary Findings stage:
External Report
Findings Summary Report o Other audit stages:
Rebuttal Detail Report
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Rebuttal Summary Report
Narrative Findings Report (Record of an Audit Finding)- Narrative Findings Report describes the type of finding (i.e. non-covered services, lack of documentation, etc.) identified in the audit. The narrative findings report lists the WI Administrative Code and handbook citations which support the recoupment. Each audit may have more than one type of narrative finding.
Technical Assistance Reports- These reports are sent to providers along with the audit reports and letters when the error did not directly cause an overpayment in this situation. These reports educate the provider on areas in which they are out of compliance with Medicaid's rules and regulations. For more information on Technical Assistance Reports, refer to the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures > SURS User Guide.
Financial Transaction Form- An auditor completes the Financial Transaction form (also known as a Cash Transaction form, or a “CT”) either to establish a recovery or to create a payout. Auditors complete the Financial Transaction form 45 days after an NIR is mailed to establish a provider recoupment in ForwardHealth/interChange 2 (iC2). The Financial Transaction form is also completed when a payout or expenditure needs to be done by the Department of Health Services (DHS)’s fiscal agent. See the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions for more information.
Promissory Note- This is documentation that is completed when a provider agrees to repay recoupment amounts over multiple installments. This includes the Promissory Note, the Promissory Note letter, and the Promissory Note payment schedule. See the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions for more information.
Fraud Referral- This is documentation that is completed when an OIG auditor refers a provider to the Medicaid Fraud Control and Elder Abuse Unit (MFCEAU) if they suspect fraudulent practices. The documentation includes the referral, the Referral Cover Sheet, and the exhibits. See the “Fraud Referrals” section for more information.
Audit Summary Letter- Auditors complete the Audit Summary Letter when they are closing out an audit. On this letter, the auditor provides background information on the audit and the final recoupment amount. See the “Closing the Audit” instructions.
Audit Routing Forms- These forms are filled out by auditors and attached to the routing folders when routing letters and reports electronically through SURS.
o MARS: The routing folder will include Page 2 of the Audit Routing Form in the left packet of the folder. This page will include comments, notes, questions, etc. communicated amongst the auditor, peer reviewer, Nursing Supervisor, and Section Chief.
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o PARS: The routing folder for a single provider audit will be empty. The routing folder for a bulk audit will have a summary sheet that includes the following for each case in the bulk audit:
Bulk ID
Case ID
Provider ID
Provider Name
Audit Stage
Projected Recoupment
Final Recoupment (if audit stage is NIR)
Recipient Records- This is documentation received from providers that should be kept together in the audit file.
Rebuttal Documentation- This is documentation submitted by providers that respond to the Preliminary Findings letter. Rebuttal documentation should be kept separate from the documentation submitted by providers in response to Records Request letters or obtained during an onsite records collection.
o MARS: Date stamp each page of rebuttal. Scan the documentation and save it to the audit file at L: > Oig Ma > Audit Programs
o PARS: Date stamp the envelope in which the rebuttal documentation was mailed and date stamp the first page of the rebuttal documentation. If desired, scan the documentation and save it to the H: drive or L: drive.
Correspondence with providers- Auditors should keep a contact log in the audit folder of any written and telephone conversations they have with providers. The contact template is called “Phone Record” in the SURS documentation panel.
o MARS auditors will house all provider communications in the Communications or Phone Records subfolder in the audit file and upload to SURS prior to closing the case.
Workpapers- Auditors should keep all spreadsheets, checklists, etc. they used to review records and track audit findings. If instructed by management, these workpapers should be uploaded to the case prior to closing the audit.
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LOCATION OF AUDIT DOCUMENTATION
Auditors can find the following audit documentation and templates in the SURS Case Tracker Documentation panel.
Audit Authority Letter
Audit Plans
Audit Checklists
Audit Comment Charts (these were created to ensure comments entered in SURS will be consistent on each audit no matter which auditor is working on the audit)
Audit Folder Route Forms
MFCEAU Referral (for fraud referrals)
Narrative Finding Reports
Promissory Note
Promissory Note Payment Schedule
Record Request Attachments
Technical Assistance Reports
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NEW DOCUMENTATION FOR SURS CASE TRACKER
In order to make documents easily accessible and to ensure that documents are current, documents in the SURS Documentation panel are named using a consistent naming convention. Anything that will be uploaded into the SURS Documentation panel needs to follow the naming convention. Auditors should review the names of current documents for a sense of how documents are named. Examples: (each “level” is part of the naming convention) Audit Checklist
Provider/Program Type Specific Service
Example: Audit Checklist DME Breast Pump
Audit Plan Provider/Program type
Specific Service
Example: Audit Plan Pharmacy Compound Drug Audit Comment Chart
Provider/Program Type Specific Service
Example: Comment Chart DME DMS
Narrative Finding (MARS uses the word “Finding” for Findings of Fact documents; PARS uses the term “Narrative Finding”)
Provider/Program Type Specific Service
Type of Finding
Example: Narrative Finding DMS Mickey Button Noncovered Record Request Attachment
Provider/Program Type Specific Service
Example: Record Request Attachment DME Breast Pump
Technical Assistance (Tech Assist) Provider/Program Type
Specific Service Type of TA
Example: Tech Assist DME Breast Pump Form Incomplete
Any new documents created by auditors should be reviewed by the appropriate supervisor. Once the documents are approved, the supervisor or section chief will ensure the document is properly named and upload it to the main Documentation panel of SURS.
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The following document types have been uploaded into SURS: Audit Plans, Narrative Finding Reports, Technical Assistance Reports, Comment Charts, Checklists, and templates.
o If a document needs to be uploaded into SURS that does not fit into any of the above types, please let the supervisors know so a new category and convention can be created.
Auditors are able to use the search function in SURS to locate a document using categories, section and keywords (i.e. Audit Plan). Auditors can also sort documents listed in the documentation panel by clicking on the column headings (i.e. Name, Section).
Once an auditor finds the document they want to use, they must save the document to their computer prior to making any changes to the document.
Only current copies of the documents will be visible in the Documentation panel; however, older versions of documents are soft deleted once new versions are uploaded. Admin and management are able to open older versions if auditors need to see a previous version.
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Audit Letters
There are many letters which can be issued by an auditor during the course of an audit. The following is a description for some of the most commonly used letters generated during the audit process. For information on generating letters, refer to the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures.
1. Audit Announcement Letter – Audit Announcement letters are mailed to providers when auditors will be going onsite to collect records for audit. OIG management determines if an Audit Announcement letter should be sent and will inform the auditor if they should generate the letter. This determination depends on several factors, including the type of audit, the type of provider, and whether the auditors’ presence might impact the provider’s staffing needs and/or daily operations.
a. If the Audit Announcement letter is not listed in the Name of Letter dropdown in the Letters panel of the SURS case:
i. In the Case Information Maintenance panel, select Audit Details. ii. Check the Audit Type field.
a.) If the Audit Type is not “FIELD”, ask OIG Admin staff to change the option to “FIELD”. After the Audit Announcement letter is mailed, ask Admin to change the option back to what it was previously.
2. Records Request Letter – Records Request letters are mailed to providers along with Records Request reports. The letters are produced by OIG Admin staff.
3. Desk Preliminary Findings Letter – Preliminary Findings letters are generated and mailed to providers along with the audit reports, Technical Assistance Reports (if applicable) and narrative findings reports. This letter gives the provider the amount of recoupment after the initial review of their documents, and the reports explain the findings from the audit. The Preliminary Findings letter gives the provider information on where to send rebuttal information if they choose to submit more documentation to address the findings, provides a remittance address to mail payment into if they agree with the audit results and want to pay the recoupment, and explains the provider will receive a Notice of Intent to Recover letter within 45 days if the provider has not submitted payment.
4. No Findings Letter – No Findings letters are issued if the provider has no audit findings or the potential recoupment is less than $50.
5. Amended Preliminary Findings Letter – Amended Preliminary Findings letters are issued if:
a. After reviewing rebuttal documentation, all findings are reversed and the recoupment amount is reduced to $0.
b. After reviewing rebuttal documentation, the amount of recoupment is more than $0 but below $50. The Amended Preliminary Findings letter will notify the provider of the updated recoupment amount and that OIG will not be recouping due to the minimal amount of overpayment.
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c. The findings are different from when the Preliminary Findings letter was issued. For example, if a provider does not submit records after receiving the Records Request letter, the auditor will issue the Preliminary Findings letter for a full recoupment using Lack of Documentation as the finding. If the provider then submits documentation which changes the finding from lack of documentation to non-covered services, then the auditor would issue an Amended Preliminary Findings letter so the provider has a chance to respond to the new audit findings.
Note: If, after a review of the provider’s rebuttal documentation, there are no new finding types, a Notice of Intent to Recover (NIR) letter should be mailed.
Example 1: Provider does not submit documentation in response to the Records Request letter for Claims A and B. Claims A and B both have findings for lack of documentation; OIG issues a Lack of Documentation Narrative Finding with the Preliminary Findings letter. If the provider submits documentation for one claim and the finding changes from Lack of Documentation to Non-covered Services, the auditor will issue an Amended Preliminary Findings letter. This is because the provider did not receive the Non-covered Services Narrative Finding with the Preliminary Findings letter.
Example 2: In response to the Records Request letter for Claims A and B, provider submits documentation for Claim A, but not for Claim B. The Preliminary Findings External Report shows Claim A had a finding for non-covered service and Claim B had a finding for lack of documentation. If the provider submits documentation for Claim B and the finding changes to non-covered service, the auditor will issue an NIR letter. This is because the provider already received the Non-covered Services Narrative Finding with the Preliminary Findings letter.
d. Changes are made to the narrative findings report or the Preliminary Findings Report because there was missing Administrative Code or Handbook citations that should have been included on the report that was sent to the provider. To prevent this situation, auditors should always review their findings and make sure the narrative findings report contains the appropriate citations.
e. The audit did not initiate with a Records Request letter or an onsite records collection, and the provider’s first notification that they are being audited is a Preliminary Findings letter. This will happen if most or all of the findings stem from reviewing data instead of provider documentation to determine recoupments.
MARS: If the first audit letter is a Preliminary Findings letter and the provider submits rebuttal documentation that does not reverse all the audit findings, auditors should confer with management as to whether the provider will receive an Amended Preliminary Findings letter or an NIR letter.
PARS: If the first audit letter is a Preliminary Findings letter and the provider submits rebuttal documentation that does not reverse all the audit findings, auditors will issue an Amended Preliminary Findings letter so the provider has an additional opportunity to submit rebuttal documentation.
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f. If instructed by management: After reviewing rebuttal documentation, the recoupment amount decreases (but the recoupment amount is $50 or greater) or there are changes to the preliminary findings (even if there is no change to the recoupment amount).
6. Notice of Intent to Recover Letter (NIR) – The NIR letter is generated about 45 days after the provider is mailed either a.) a Preliminary Findings letter or b.) an Amended Preliminary Findings letter for $50 or more, and the provider does not submit payment for recoupment. The NIR letter is sent to providers who respond to the Preliminary Findings or Amended Preliminary Findings letter by submitting rebuttal documentation. The NIR includes the recoupment amount DHS intends to recover, the remittance address to which the provider may submit payment, and the mailing address if the provider wants to file an appeal within 20 days from the date they received the NIR letter. The provider receives audit reports with the NIR letter showing the recoupment amount.
If the provider submitted payment for some (but not all) of the audit findings, the NIR letter should acknowledge the provider payment amount and indicate the remaining overpayment.
Example: a. The provider receives a Preliminary Findings letter with a recoupment amount of
$1000. b. The provider mails in check for $400 for the findings they agree with. c. The provider submits rebuttal for the $600 in findings they disagree with. d. The auditor reviews rebuttal and determines the rebuttal does not reverse any
findings. e. When entering rebuttal comments, the auditor leaves the findings as they were at
Prelim (because the rebuttal did not reverse the findings). i. The auditor enters a Provider Agreed Amt of “$0.00” for the findings for
which the provider submitted rebuttal. ii. The auditor enters a Provider Agreed Amt of [recoup amount] for the
findings for which the provider agreed/submitted payment (Step b). Note: if the provider sends a check and does not specify the claims that the check is for, the auditor should contact the provider and ask for a list of those claims. If the auditor is unable to determine which claims the provider submitted for (i.e. the dollars do not match up to the check), the auditor will enter a Provider Agreed Amt of “0.00”.
f. When the rebuttal reports and NIR letter are generated, the recoupment amount will
still display as $1000 (because no findings were actually reversed). Therefore, the auditor will add a sentence to the NIR letter acknowledging the provider’s payment of $400 and state the remaining recoupment is $600.
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7. Notice of Intent to Recover Letter No Response (NIR No Response) – The NIR No Response letter is generated about 45 days after the provider is mailed either a.) a Preliminary Findings letter or b.) an Amended Preliminary Findings letter for $50 or more. This type of NIR letter is mailed to providers who did not submit any rebuttal documentation to the Preliminary Findings or Amended Preliminary Findings letter and have not submitted payment for the recoupment. The NIR No Response letter informs the provider of the amount to be recouped, the remittance address to submit payment, and the mailing address if the provider wants to file an appeal within 20 days of receiving the NIR No Response letter in the mail. The provider receives audit reports with the NIR No Response letter showing the recoupment amount.
8. Amended NIR Letter – The Amended NIR letter is sent to providers who submit documentation for review after they received the NIR letter and requested an appeal. The Amended NIR letter repeals the previous NIR letter that was mailed to the provider, and it informs the provider of the revised recoupment amount. The Amended NIR letter does not give the provider appeal rights since they received those rights when they received the NIR letter. The provider will be given the remittance address to mail in payment. If a provider submitted an appeal request, the auditor will forward the provider’s information to the paralegal in the Office of Legal Counsel (OLC) and the paralegal will send the provider information on how to withdraw their appeal.
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Overview of the Audit Process
Reference the flowchart located at L: > Oig Ma > Auditor > Audit Procedures for an overview of the audit process.
Obtaining Records For most audits, documents will be obtained from providers via one of two methods:
1. A Records Request letter is mailed to the provider along with a list of the recipients chosen for audit. The Records Request letter lists the documents that the providers are to submit to OIG for review.
2. Auditors do an onsite records collection. OIG management will instruct auditors as to whether or not an Audit Announcement letter will be mailed to the providers before the auditors arrive, or if the records collection can be scheduled by phone with the provider shortly before the records collection. Two to three auditors are usually sent to a provider’s location to collect records; the monthly audit schedule will indicate if an auditor is supposed to go onsite to scan records.
MARS: The auditor will choose their onsite partner(s) to assist with the records collection.
PARS: The monthly audit schedule will indicate who will be assisting the auditor. The auditor assigned to the case will serve as the lead auditor during the site visit and the other auditor(s) will assist. In some instances, auditors collecting records may also be asked to conduct Affordable Care Act (ACA) site visits (refer to the instructions in the L: > Oig Ma > Auditor > ACA > ACA Provider Certification Research Instructions folder for more information). Roles: Lead auditor: The lead auditor will make all of the arrangements (reserving vehicle, scanner and laptop; determining travel route; etc.) for the trip, or coordinate arrangement duties with the assisting auditor(s). The lead auditor will also be in charge during the site visit by communicating with the provider and organizing the records collection. The lead auditor
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may designate some of these duties to the assisting auditor(s), but is ultimately responsible for ensuring arrangements are made. Assisting auditors: The assisting auditors help the lead auditor scan the records and reassemble the provider’s files after scanning.
Preparing for Onsite Records Collection
To prepare for an onsite records collection: 1. Use the internet to confirm the provider’s hours of operation. If the provider does not have
a website, call the provider to verify their hours of operation. If the provider does not have a working phone number, notify the appropriate supervisors.
2. Use an online map website to get directions to the provider’s location and to estimate the driving time.
3. Reserve the equipment for the onsite records collection by filling out the appropriate template:
MARS
Equipment Needed Checkout Date Checkout Time Return Date Return Time
Scanner #1
Scanner #2
Laptop #1
Laptop #2
IronKey #1
IronKey #2
Cell Phone
GPS
Camera
Power Strip #1
Power Strip #2
Cart #1
Cart #2
Other
2nd Auditor Name:
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PARS Note: Auditors do not need to use this exact template, but their email to Admin staff should contain the same type of information.
Equipment Needed Checkout Date Checkout Time Return Date Return Time Scanner #1
Scanner #2
Laptop #1
Laptop #2
IronKey #1
IronKey #2
Cell Phone
GPS
Camera
Other
2nd
Auditor Name:
If a third auditor will also be assisting in the onsite records collection and additional equipment will be needed:
Add additional lines (i.e. “Scanner #3”, “Laptop #3”).
Add “3rd Auditor Name” below “2nd Auditor Name”.
The Checkout Date may not necessarily be the same day as the records collection (i.e. if the equipment is being checked out the day/night before the records collection). Enter the date the equipment will actually be picked up.
For Checkout Time, “A.M.” and “P.M.” are acceptable.
The Return Time can be an estimate; however, try to be as close as possible in case Admin is coordinating equipment use amongst numerous auditors.
4. At least 24 hours prior to requested checkout time, email the completed template to DHS OIG Admin email and either the MARS Medical Audit Coordinator (for equipment requests from MARS staff) or the PARS Operations Program Associate (for equipment requests from PARS staff).
5. DHS OIG Admin and either the Medical Audit Coordinator (MARS) or the Operations
Program Associate (PARS) will each send an email response confirming if the equipment is available and where the auditor(s) can pick it up on the Checkout Date. The auditor should not respond to the confirmation emails nor check out the equipment until they have received the two confirmation emails.
6. On the Checkout Date, check out the equipment. Other notes:
If the equipment will be given directly to another auditor for a different onsite records collection (meaning the equipment will not be physically returned to Admin staff on the Return Date), communicate this via email to Admin staff. The auditor receiving the equipment is responsible for updating the checkout sheets with Admin before taking the equipment out of the office.
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The above steps do not need to be followed when reserving any equipment for
internal office use for less than a day. Handling the equipment:
Pick up the loaner equipment in advance so auditors can test it (see reference document located at L: > Auditor > Audit Procedures). State cell phones should be charged.
Turn-off WIFI on laptops and scanners. Verify all of the loaner equipment works before leaving the building. Check and charge all equipment batteries. For security purposes, do not connect loaner laptops or scanners to wireless networks
outside of this building. Save all scanned files to a secure flash drive. Auditors should keep the secure flash drive
with them. OIG laptops, scanners and cell phones must be kept with the users, or secured in a
locked car trunk during travel. If auditors stop for lunch on the way back to the office, they must lock all equipment and files in the trunk of the car. If keeping the equipment overnight, do not leave the equipment in a locked car trunk, especially if the temperature will be extremely hot or cold (as this can damage the equipment).
7. Reserve a car through Fleet.
a. To reserve a car at 1704 South Park St. (the main Fleet location): i. Access the Fleet Portal (https://fleetportal.wi.gov/my.policy) ii. Select Reservation. iii. Enter the appropriate information. In the “Customer Use Code”, enter
H80000MARS or H80000PARS. Note: If there will be an ACA site visit along with records collection, enter the Customer Use Code for ACA (refer to the instructions in the L: > Oig Ma > Auditor > ACA > ACA Provider Certification Research Instructions folder for more information). PARS: Auditors may choose to split the Use Code percentage between the H80000PARS code and the ACA Customer Use Code (i.e. 50% and 50%), but at a minimum auditors must enter the ACA Customer Use Code if there will be an ACA site visit.
b. To reserve a car at 1 West Wilson: i. Access the Fleet page on the DHS WorkWeb
(https://dhsworkweb.wisconsin.gov/building-space/fleet.htm). ii. Under the heading “Reserve a DHS vehicle”, select the “instructions here”
link for reserving a vehicle via Outlook.
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iii. Follow the instructions.
8. Print each auditor a copy of the Provider – Recipient List Report (or the list of information that the auditors will use to locate records – see audit-specific guides for more details). Take these copies to the records collection.
The Provider – Recipient List Report is generated in the Reports panel of the SURS case. It can be placed into Excel, sorted and organized as needed, and printed in spreadsheet format. This version of the report can be saved to the Documentation panel in the case.
9. Print a copy of the Audit Authority letter, located in the SURS Documentation panel. Take
this letter to the records collection.
10. Print a copy of the Onsite Records Collection Notes Template (located in the SURS Documentation panel; the Section should be “Bureau”) or save the document onto a laptop.
11. MARS: Print a copy of the Onsite Attendance Sheet (located in the SURS Documentation panel). PARS: Check with PARS management to determine if an Onsite Attendance Sheet should be filled out during the records collection, based on the provider/audit type.
12. Take name and phone number of provider services and their field representative to the records collection in case the provider asks questions about billing, policy, etc. While auditors may answer questions about the audit process, they should inform the provider that other questions should be directed to provider services or their field representatives. To identify the appropriate provider field representative:
a. Log into the ForwardHealth Portal. b. Select the Providers icon.
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c. Under the “Quick Links”, select Find/Contact your Provider Relations Representative.
d. Locate the county in which the provider is located or provides services. e. Determine which Specialty Group (1 or 2) the provider falls under. f. Locate the appropriate provider field representative and their contact information.
Onsite Records Collection Note: For some audits, the audit will be conducted onsite instead of bringing the records back for a desk review. Refer to the audit-specific guides located at L: > Oig Ma > Auditor > Audit Procedures to determine if the audit will be conducted onsite. The following may be altered to suit the needs of the auditors and the providers depending on the set up of the provider’s facility, location of the provider’s records, etc. Upon arrival at the provider’s location:
The lead auditor will introduce themselves and the audit staff to whoever is in charge.
Explain the reason of the visit (to collect records for the purpose of audit).
Provide the Audit Authority Letter, which explains the function of the OIG. If the provider asks why they were selected for audit, explain to the provider that they may have been randomly selected (and that, when they sign the Medicaid provider agreement, they acknowledge that they may be audited by the Department of Health Services). Inform the provider that the auditors are there to scan documentation pertaining to certain claims billed to and paid by Medicaid.
If a provider refuses to provide records, explain all Medicaid providers agreed to be audited when they signed up to be a MA provider. If they refuse to provide the records, inform them that they will be sent a preliminary finding for a total recoupment of all claims included in the audit. After explaining this, ask the provider if they are refusing to provide their records. If they say yes, then thank them and contact the appropriate supervisor to let them know about this or any other issues.
Have the provider staff in attendance fill out a line on the Onsite Attendance Sheet, if applicable. Note: “Entrance” means the attendee was present at the beginning of the records collection and “Close” means the attendee was present before the auditors left the site.
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Request a workspace where the auditors can set up the laptops and scanners, preferably somewhere where the auditors will not interfere with employees’ work duties.
Inquire about the location of restrooms/ask for a brief tour.
Communicate the scope of the audit to the provider.
If possible, communicate the number of members in the audit to the provider.
Present the list of recipients, prescriptions, etc. to the provider and ask them to bring the records/files to the auditors for scanning. If the list is long, either divide it into sections and give it to the provider in sections, or give the entire list to the provider and ask them to give records/files to the auditors as the provider finds them.
Explain the next steps the auditor will follow in the audit process (this may also be done after all the records have been scanned):
o Collect records and return to the office to review. o Review claims in conjunction with admin code and policy manuals to determine
compliance with Medicaid. o Produce letter (which will include the auditor’s name and contact information) and
report with findings. o Schedule exit conference with provider (if applicable). o Rebuttal period – provider has 30 days from receipt of preliminary audit findings to
submit documentation. If the provider expresses concern regarding the 30-day deadline, let the provider know they can contact the auditor on the Preliminary Findings letter and discuss the deadline.
o Upon review of rebuttal documentation by the auditor, an updated letter and report will be generated.
o Note: Advise provider to not adjust any claims regarding the recipients during the scope of the audit.
Set up the equipment for scanning records/files.
During records acquisition:
On their list(s)/report(s), the auditors will mark off the records/files once they are given to the auditors for scanning. They will remove staples from the files, scan them, and reassemble them in the manner that the provider gave them to the auditors.
Once all of the records are scanned, pack up all state equipment. Before leaving the provider’s location:
If needed, return the original files to the provider.
Thank the provider for their time and for providing the records.
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Answer and document any of the provider’s questions.
If it has not already been done, explain the next steps the auditor will follow in the audit process.
Provide business card/contact information. Inform the provider that until they receive an OIG audit letter with the appropriate auditor’s contact information, the provider may contact the lead auditor with questions.
Notes: 1. Dress professionally and be well groomed. Dress comfortably and wear practical footwear,
as the visit may take several hours or all day and require a lot of standing.
2. Bring appropriate identification (i.e. State ID badges).
3. Do not comment on the records and whether or not they are in compliance. Do not give feedback during the site visit; auditors should not discuss the documentation amongst themselves at the provider’s location.
4. If the provider asks who the auditor assigned is, the lead auditor should tell the provider that they cannot guarantee who will be assigned to the audit and that the auditors present today were assigned to collect the records. The lead auditor may present a business card to the provider and say that until the provider receives an audit letter with the appropriate auditor’s contact information, the provider may contact the lead auditor with questions.
5. Do not answer billing or policy questions while onsite. Direct the provider to their field rep and provider services.
6. Auditors are not allowed to accept anything from providers, including food or beverages.
7. It is best to stay at the provider’s location until all files have been scanned. If auditors have to leave for any reason, all state equipment must be packed up and taken with them.
After the site visit:
1. Return Fleet vehicle to Fleet (refer to the Fleet Policies on the Fleet Portal for information about returning vehicles).
2. After returning to the office, the lead auditor will complete the Onsite Records Collection Notes Template. The lead auditor may ask an assisting auditor to verify the accuracy of the notes. The lead auditor will upload the document to the documentation panel in the case.
3. Scan the Onsite Attendance Sheet (if applicable) and upload it into the case.
4. Save the scanned documents.
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MARS: Each auditor will upload documents from their secure flash drive to the audit file on the L: drive (see Chapter 2, “Audit Documentation”). Once the documents are uploaded, delete the files from the secure flash drive. PARS: The lead auditor copies files of scanned documents from the secure flash drive(s) and uploads them into their auditor folder on the L: drive. Once the documents are uploaded, delete the files from the secure flash drive(s).
5. Make sure the equipment is in the same condition it was in when it was checked out (equipment is clean, all cables are placed with appropriate devices, records are deleted from storage devices, etc.). Return the equipment to Admin (this may be done by the lead auditor or by any of the assisting auditors).
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Preparing for the Audit When the monthly audit schedule is published by management, auditors should review the schedule to determine the type of audit assigned. Auditors should then do the following:
Receive or Retrieve Audit Records
If a Records Request letter was mailed to the provider(s) in the audit:
MARS: Contact the Medical Audit Coordinator for the records.
PARS: Receive the records from Admin staff at the beginning of the month. If the records will be collected from the provider(s) onsite, follow the “Preparing for Onsite Records Collection” and “Onsite Records Collection” instructions.
Case Assignment
Admin will assign the audit cases in SURS at the beginning of the month. Verify the case has been appropriately assigned (refer to the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures). If it has not, email Admin and ask that the case be assigned.
Claims Data
MARS The audit case will be created by the Medical Audit Coordinator or the Data Analytics Section (DAS). For a summary of the claims:
1. In the Case Information Maintenance panel, select Reports. 2. In the Name of Report dropdown, select Audit List Report. 3. Select gen report. The report can be saved as a PDF or an Excel file.
PARS Depending on the type of audit, DAS will use various data analytics tools to select claims for audit. For certain audit types (refer to audit type-specific guides at L: > Oig Ma > Auditor > Audit Procedures), when the DAS opens a case, they will upload an Excel spreadsheet containing information for the claims in that case into the Documentation panel of that case. This is called the “Master File”. If this file is present, save the Master File to the H: or L: drive and, if desired, add any rows or columns that will help with tracking audit findings. Example of columns that might be added to the Master File for a DME/DMS audit:
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RESEARCH
1. Research the Wisconsin Administrative Code, appropriate Medicaid Handbooks, and all applicable Provider Updates for the scope of the audit for the following information:
Covered and noncovered services
Prior authorization (PA) requirements
Required documentation (i.e. forms, prescriptions, medical records) to support the claim(s)
Miscellaneous criteria that is specific to the audit (i.e. quantity allowed per year and the max fee schedule)
a. To view Wisconsin Administrative Code:
i. Access the Wisconsin State Legislature website (https://docs.legis.wisconsin.gov/).
ii. Under “Administrative Rules”, select Administrative Code. iii. Select Department of Health Services. iv. Select Chs. DHS 101-109; Medical Assistance. v. Select a chapter.
Note: Selecting a title will display the chapter on the website. Selecting the .pdf icon will display a .pdf version of the chapter.
b. To locate Medicaid handbooks and Provider Updates:
i. Access the ForwardHealth Portal (https://www.forwardhealth.wi.gov/WIPortal/Default.aspx).
ii. Select Online Handbooks. iii. Select Updates and handbooks. iv. Locate the appropriate handbooks and Provider Updates.
a.) To view prior handbooks: i.) Under the Online Handbook Archive, locate the year(s)
applicable to the audit scope. ii.) Select the appropriate “Published policy through mm/dd/ccyy”
link. iii.) Select the appropriate provider type. A .pdf copy of the
handbook will appear. b.) To view prior Provider Updates:
i.) In the Updates by Year dropdown, select the appropriate year. ii.) Select GO. iii.) Review the appropriate updates. Updates are organized in
reverse chronological order of publication date.
2. In the Documentation panel in SURS, locate the following documents applicable to the audit/provider type (descriptions of these documents can be found in Chapter 2):
Audit Plans
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Record of an Audit Finding Reports (also called Findings of Fact or Narrative Findings)
o For MARS’ reports, the document will have “Finding” as the first word in the name.
o For PARS’ reports, the document will have “Narrative Finding” as the first two words in the name.
Technical Assistance Reports
Audit Checklists
Comment Grids (for MARS audits) or Comment Charts (for PARS audits) a. If some or none of these documents exist for the audit:
i. Confer with management to see if new document templates should be created. MARS: Confer with management if new comments are needed for the
Comment Grids. ii. Create the document templates using the format of pre-existing documents. iii. Submit the documents to management for review and approval.
3. Refer to the Comment Grids or Comment Charts in the SURS Documentation panel for a sense
of what should be reviewed for the audit. Administrative code and statute are the first consideration for determination of appropriate audit findings. Auditors may also want to confer with other auditors who have done similar audits to see if there is anything else to take into consideration.
4. Review information in prior audits of the provider. a. Log into SURS. b. In the SURS Case Tracker header menu, select Case Search. c. Enter the provider’s name or Provider ID.
Note: Providers may have more than one Provider ID depending on changes in ownership, multiple locations, etc.
d. Select search. Search results will appear below the search panel if: The provider has been audited by OIG before. OIG has received a complaint regarding the provider (each complaint will receive
its own case number). OIG has reviewed a provider’s Medicaid application or recertification due to the
Affordable Care Act (ACA). Search results can be sorted by any of the column headers (Case ID, Audit Scope, Auditor, etc.)
e. Use information in the Case Information Maintenance subpanel (Comments, Documentation, Letters, Complaint, Reports, Audit Appeals, etc.) to obtain details such as:
ACA history
Complaint history (Case Origin will be “Complaint”)
Record collection notes
Type of audit findings (these will be in the Summary Reports and External Reports)
Previous Technical Assistance Reports
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Credible Allegations of Fraud (CAFs)
Rebuttal
Appeals
MAX FEE SCHEDULES
To identify the Medicaid maximum reimbursement fee (Max Fee) and quantity limits or life expectancy for a particular Procedure Code, use the following methods:
Downloadable Max Fee Schedules
Interactive Max Fee Search
Max Fee Panel in iC2 Some information may be visible via one method but not the others. For example, quantity limits can be viewed on the downloadable Max Fee schedules but not on the interactive Max Fee search or the iC2 Max Fee panel. Downloadable Max Fee Schedules Note: This may be more relevant to DME/DMS audits than other audits, as DME/DMS codes are the only ones with a PDF version of the Medicaid Fee Schedules.
1. Log into the ForwardHealth Portal (https://www.forwardhealth.wi.gov/WIPortal/Default.aspx).
2. In the “Providers” category of links on the left side of the screen, select Fee Schedules.
3. In the “Quicklinks” menu on the right side of the screen, select Download Fee Schedules.
4. For DME/DMS Procedure Codes: Under the “Downloadable Max Fee Schedules (BadgerCare Plus and Medicaid providers only” paragraph is the sentence “To view PDF-style reports of the Max Fees.” Select view. A page will appear with the Medicaid Fee Schedules in PDF format.
5. Select the PDF for the Disposable Medical Supplies (DMS) Index or the Durable Medical Equipment (DME) Index. The effective date for that index will be at the bottom of the pages. If the effective date is after the dates of the audit scope, locate the appropriate index for the audit scope.
a. To select a previous index: i. Return to Step 4. ii. Select DME and DMS Archives. iii. Locate the appropriate date that applies to the dates of the audit scope. iv. Select the corresponding index.
6. Find the appropriate procedure code and modifier (if present) and identify:
The Max Quantity Per Month (for DMS items) or Life Expectancy (for DME items)
Rental/Prior Authorization (PA) requirements
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Interactive Max Fee Search
1. Log into the ForwardHealth Portal (https://www.forwardhealth.wi.gov/WIPortal/Default.aspx).
2. In the “Providers” category of links on the left side of the screen, select Fee Schedules. 3. In the “Quicklinks” menu on the right side of the screen, select Interactive Max Fee
Search. The Fee Schedule Search panel will appear.
4. In the Financial Payer* dropdown, select Medicaid. 5. In the Service Area* dropdown, select the service area that is applicable to the Procedure
Code; usually this information can be gleaned from researching the service in the Medicaid Handbooks.
6. In the Procedure Code field, enter the Procedure Code. 7. In Date of Service, enter the first day of the audit scope. 8. Select search. The Billing Rules for the Procedure Code will appear.
Example:
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9. Scroll below the Billing Rules and select Max Fee Rates. The Max Fee Rates table will appear. Example:
10. Locate the rows with the relevant provider type/specialty, modifier, member age, etc. Max Fee Panel in iC2
1. Log into iC2. 2. Select Main Menu. 3. Select BPA. 4. Select Procedure. 5. In the Procedure field, enter the Procedure Code. 6. Select search. The Procedure Code information panel will appear. 7. Select Open Tab. 8. Select Procedure. 9. Select Max Fee. The Max Fee subpanel will appear. 10. Using the Effective Date and End Date columns, locate the Max Fee(s) that are applicable to
the claims in the audit scope. If a rate was applicable for a particular modifier for the Procedure Code, a modifier will be in one of the modifier columns.
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Completing the Audit Plan MARS
1. As soon as the audit is assigned for the month, create the audit plan for the assigned audit.
2. Create a Peer Review Folder inside the prelim folder on the L Drive (see Chapter 2, “Audit Documentation”) and save a copy of the MARS Peer Review Audit Checklist (located in the SURS Documentation panel) into that folder.
3. Save a copy of the audit plan into the Peer Review Folder as well. Use the naming convention described in the “Completing Peer Reviews” subsection of the “Peer Review” section later in this process document.
4. Either via email or by routing a burgundy folder, inform the Peer Reviewer assigned for the audit (see the “Assigning Peer Reviews” subsection of the “Peer Reviews” section later in this process document) that the audit plan is ready for peer review.
5. The assigned peer reviewer will peer review the audit plan following the instructions in the “Completing Peer Reviews” subsection of the “Peer Review” section later in this process document. The peer reviewer will peer review only the audit plan and complete only the audit plan section of the MARS Peer Review Audit Checklist at that time. The other sections of the checklist will be completed when the remainder of the audit documentation is ready for peer review.
The peer reviewer will inform the auditor that peer review is complete either via email or by returning the burgundy folder.
6. Once the peer review of the audit plan is complete, upload the audit plan into the documentation panel for the audit in SURS Case Tracker. Supervisor review of the audit plan will occur when the preliminary audit findings for the audit are routed for supervisor review.
7. Begin the audit. PARS
1. Before conducting the audit, complete the Audit Plan (refer to the “Audit Documents and Descriptions” subsection of the “Audit Documentation” section in Chapter 2).
2. Upload the Audit Plan into the Documentation panel of the case (refer to the “Uploading Documents in SURS” instructions in the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures).
3. Route the Audit Plan for peer review along with other audit documentation (refer to the “Routing Audit Documents for Peer Review and Management Approval” section) when routing the Preliminary Findings letter(s) and report(s).
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Conducting the Audit The specific documentation, claims data, etc. that will need to be reviewed varies depending on the type of audit. Refer to the appropriate audit guide located at L: > Oig Ma > Auditor > Audit Procedures or L: > OIG MAR Directory for specific instructions on what to review. If an audit guide or training materials do not exist for the type of audit, refer to OIG management or other audit staff for assistance. The following subsections describe how to access information that may be pertinent to the audit:
COMPLAINT REPORTS (MARS)
When beginning an assigned audit, the auditor should email DAS and ask for a complaint report for the provider. The report will include the following information:
Billing Provider ID
Billing Provider Full Name
Case Create Date
Case ID
Complaint Status Comment
Complaint Comment
Recipient ID Recipient Full Name
DAS will inform the auditor if the provider has had no prior complaints. The auditor should also e-mail DAS and ask for a complaint report when the auditor becomes aware of a new complaint regarding the provider, when requested by MARS management, when routing the audit at the various audit stages for peer review and management approval, or when the report becomes outdated during the audit process.
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PRIOR AUTHORIZATIONS
Prior Authorizations in iC2
To determine if a service/quantity billed on a claim has been prior approved:
1. Log into interChange 2 (iC2).
2. Bring up the claim.
3. Select Open Tab.
4. Select the [Claim Type] Claim.
5. Select Prior Authorization. A Prior Authorization subpanel will appear.
6. Select the PA Number. A PA information screen will appear.
7. Select Open Tab.
8. Select Prior Authorization.
9. Select Line Item.
10. Locate the Authorized Eff Date and Units Authorized fields. a. Units may indicate either a quantity or a measure of time. In the Medicaid
Handbook that corresponds to the audit, refer to the Prior Authorization chapter for more information.
11. Repeat Steps 7 and 8.
12. Select External Text to view any notes made by the PA reviewer.
To search for a PA without bringing up the claim first:
1. Log into iC2.
2. Select Main Menu.
3. Select Prior Authorization.
4. Select PA Search. The PA search panel will appear.
5. Enter search criteria (i.e. PA Number).
6. Select search. A search results subpanel will appear.
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7. Review the results and select the appropriate service/item. A detail panel for that PA will
appear.
8. Select Open Tab. 9. Select Prior Authorization. 10. Select Line Item. 11. Locate the Authorized Eff Date and Units Authorized fields.
a. Units may indicate either a quantity or a measure of time. In the Medicaid Handbook that corresponds to the audit, refer to the Prior Authorization chapter for more information.
12. Repeat Steps 8 and 9. 13. Select External Text to view any notes made by the PA reviewer.
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Prior Authorization Documentation
Some audits may necessitate the review of PA documentation to confirm what services/quantity of services Medicaid has approved a provider to provide.
1. Log into Project Workbook (https://pwb.prod.healthcare.wi.local/Wisconsin/Default.asp).
2. Select the + symbol next to the “State/Madison Users” link.
3. Select “Prior Auth Workflow”.
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4. Sign into OnBase. 5. From the Documents Type Groups dropdown, select Prior Auth.
PARS: If Prior Auth does not appear as a dropdown option, contact a supervisor and ask them to request access to this option.
6. Double left click in the Document Types list and highlight all Document Type options. The Keyword search options for “PA Number”, “PA Process Type”, and “Recipient ID” will appear.
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7. Search by PA Number or Recipient ID. 8. Review the corresponding PA documentation for additional information.
a. Select the name of a document. The document will appear in the display area.
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PROVIDER CERTIFICATION
1. Log into iC2.
2. Select Main Menu.
3. Select Provider.
4. Select Search.
5. In the Provider ID field, enter the provider’s Medicaid ID.
6. Select search. a. If only one result matches the search criteria, the Provider Information panel will appear. b. If multiple results appear, select the entry with a Financial Payer of TXIX.
Example:
7. On the right side of the panel, review the provider’s Contract information.
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RECIPIENT NAME CHANGE
Because these audits are retrospective reviews, a recipient’s name may change between the time they received a service and the time that OIG audits a claim. If a provider submits documentation for a recipient and the names do not completely match, verify if the recipients are the same.
1. Log into iC2.
2. Select Main Menu.
3. Select Member.
4. Select Search.
5. Enter the recipient’s Member ID.
6. Select search.
7. On the recipient’s information panel, locate the Name and Prev Name fields. If there are entries in the Prev Name fields, the recipient’s name changed.
Example:
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THIRD-PARTY LIABILITY
According to the Medicaid handbooks, except for a few instances, Wisconsin Medicaid or BadgerCare Plus are the payer of last resort for any covered services. Therefore, the provider is required to make a reasonable effort to exhaust all other existing health insurance sources before submitting claims to Medicaid or to a state-contracted Managed Care Organization (MCO). During an audit, the auditor will determine if a provider correctly submitted a claim to a recipient’s primary insurance plan(s) before submitting the claim to Medicaid. For each Member ID listed, review the member’s TPL coverage in iC2 to see if it was on file when the provider submitted claims. Information about TPL can be found in the OIG TPL Reference Guide located at L: > Oig Ma > Auditor > TRAINING > TPL. This reference guide includes such topics as:
Identifying insurance coverage
Determining when TPL was added to iC2
Identifying Medicare information
Determining when Medicare information was added to iC2
Understanding the Enrollment Verification System (EVS)
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THIRD-PARTY LIABILITY QUERY
For audits with a high number of recipients, auditors can use a query in Business Objects to determine which of those recipients had TPL during the audit scope. Auditors can ask the Advanced Auditor or the Data Analytics Section for assistance in acquiring or building this query.
1. In Business Objects, create a query in the TPL Universe with the following Result Objects and Query Filters:
2. In the Member ID query filter, enter the IDs listed in the audit. a. From the Documentation panel of the SURS audit case, open the Master File of data
used to create the audit case(s). b. Highlight the column containing the Member IDs. c. Right-click on the column and select Copy. d. Open a blank Microsoft Excel spreadsheet. e. Paste the column into the blank spreadsheet. f. Highlight the column. g. Select the Data tab. h. Select Remove Duplicates. i. Highlight the column. j. Right-click on the column and select Copy. k. Open a blank Microsoft Word document. l. Right-click on the Word document so the Paste Options appear:
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m. Select the “Keep Text Only” option (the capital “A”). Each Member ID should appear on a separate line without any punctuation.
Example:
n. Either select “Replace” on the Editing tab, or press Ctrl + H.
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o. In the “Find what” field, enter ^p. In the “Replace with” field, enter a semicolon.
p. Select “Replace All”. The Member IDs should now run together, separated with semicolons. Example:
q. Highlight and copy the list of Member IDs. r. Return to the Business Objects query and paste the Member IDs in the Member ID
Query Filter.
3. In the Effective Date query filter, enter the mm/dd/ccyy of the end of the audit scope.
4. In the End Date query filter, enter the mm/dd/ccyy of the beginning of the audit scope.
5. Optional: a. Review the TPL Coverage Codes and Descriptions list (included after these steps)
and identify the Coverage Code(s) that represent(s) the Medicare coverage applicable to the services being audited.
b. Enter the Coverage Codes in the Coverage Code filter. c. If the auditor does not know which Coverage Codes to select, the auditor will
remove the Coverage Code filter from the query and proceed to the next step.
6. Select Run Query.
7. View the query results. For each Member ID listed, review the member’s TPL coverage in iC2 to see if it was on file when the provider submitted claims (refer to the OIG TPL Training document).
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TPL Coverage Codes and Descriptions
Coverage Code Coverage Description
A MEDICARE PART A
B MEDICARE PART B
D MEDICARE PART D
01 DRUG
02 MAJOR MED
03 DENTAL
04 INPATIENT
05 OUTPATIENT
06 NURSING HOME
07 VISION
08 DME RENTAL
09 DME PURCHASE
10 HOME HEALTH
11 MED SUP DRUG
12 MED SUP MAJOR MED
13 MED SUP DENTAL
14 MED SUP INPATIENT
15 MED SUP OUTPATIENT
16 MED SUP NURSING HOME
17 MED SUP VISION
18 MED SUP DME RENTAL
19 MED SUP DME PURCHASE
20 MED SUP HOME HEALTH
21 MEDICARE ADVANTAGE
22 MEDICARE COST
23 DENTAL ONLY
24 HIRSP DRUG ONLY
25 LTC ONLY CASH
26 LTC ONLY REIMBURSEMENT
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CLAIM ADJUSTMENTS
Identifying Adjusted Claims Using Business Objects
Business Objects can be used to determine if claims in an audit were adjusted during the course of the audit. Auditors may choose to follow these steps in order to remove adjusted claims from the audit reports or to verify if a provider has adjusted claims (if a provider indicates in their rebuttal documentation they have adjusted claims). OIG management will inform auditors if there are certain audit/provider types for which auditors should always check for adjustments before generating audit reports.
1. Either request the Adjustment ICN Query from the PARS Advanced Auditor or the Data Analytics Section, or build a query in the Claims universe that resembles the following:
2. From the audit working files, compile a list in Excel of all ICNs with findings. 3. Copy the list of ICNs. 4. Open a blank Microsoft Word document.
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5. Right-click on the Word document so the Paste Options appear:
6. Select the “Keep Text Only” option (the capital “A”). Each ICN should appear on a separate line without any punctuation.
Example:
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7. Either select “Replace” on the Editing tab, or press Ctrl + H.
8. In the “Find what” field, enter ^p. In the “Replace with” field, enter a semicolon.
9. Select “Replace All”. The ICNs should now run together, separated with semicolons:
10. Highlight and copy the list of ICNs.
11. Return to the Business Objects query and paste the ICNs in the ICN Query Filter.
12. Run the query.
13. If there are any ICNs listed in the “Adjusted ICN” column: a. From the Document dropdown, select “Save to my computer as”. b. Select “Excel” or “Excel 2007”. c. When the message asking “Do you want to open or save [file name] from
bo.prod.healthcare.wi.local?” appears, select “Open”. This should cause the report to display as an Excel spreadsheet.
14. If an ICN in the audit had a finding and the claim was adjusted, change the finding in the SURS Audit Findings panel to “Payable Service” and the Recoup Amount to $0. Note: The Pharmacy Audit Template has a finding option for “CLAIM ADJUSTED”.
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Adjusted Claims in interChange 2 (iC2)
Auditors can also use iC2 and search by the ICN number to see if the claim was denied or adjusted.
1. Log into ForwardHealth.
2. Select Main Menu.
3. Select Claims.
4. Select Search.
5. Enter the ICN and select search.
6. Select Open Tab.
7. Hover over [Claim Type] Claim and select the Adjustment Daughter or Mother option (Note: “Mother” refers to the original claim, and “Daughter” refers to any adjusted claim connected to the original claim).
a. If no “Adjustment Daughter or Mother” subpanel appears, the claim has not been adjusted.
b. If the “Adjustment Daughter or Mother” subpanel appears: i. Select the daughter claim. This claim should appear in its own window.
a.) If there are multiple daughter claims listed, review the Entry Dates to determine the chronological order of the adjustments.
b.) Select the final daughter claim (the claim with the most recent Entry Date). The claim should appear in its own window.
ii. Check the claim’s status. a.) If the claim has a “Deny” status, then ultimately no monies were paid
to the provider for this claim. Each time a claim is adjusted, Medicaid recoups the monies paid on the initial claim and pays monies on the adjusted claim.
b.) If the claim has a “Pay” status, then check the Paid Amount. i.) If the Paid Amount is zero, then no monies were paid to the
provider. ii.) If the Paid Amount is greater than zero, that is the amount
the provider was ultimately paid.
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Entering Audit Findings For information on how to enter audit findings in SURS, refer to the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures. Some audit types do not have a findings template in SURS. Refer to audit-specific guides to see if the findings should be entered in Microsoft Access or Excel instead of in SURS.
Generating Audit Letters and Reports
Audit results are communicated to providers via appropriate letters and audit detail reports. These letters and reports indicate the audit findings and the overpayment amount owed to Medicaid (if applicable). Refer to the “Audit Documentation” section (specifically, the “Audit Documents and Descriptions” subsection) in Chapter 2 for details regarding the various letters and reports used by MARS and PARS. For information on how to generate reports and letters in SURS, refer to the SURS User Guide located at L: > Oig Ma > Auditor > Audit Procedures. Certain audit reports will be generated in Microsoft Access or Excel instead of in SURS. Audit-specific guides will indicate how the reports for those audits should be generated.
Saving Audit Documents to Audit File (MARS) Before routing audit documents for peer review, save copies of the documents to the audit file (refer to the “Audit Documentation” section in Chapter 2). Documents that should be saved to the audit file include, but may not be limited to:
Audit Plan
Audit Letter (draft)
Audit Reports
Findings of Fact
Technical Assistance Report(s)
Complaint Report(s)
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Routing Audit Documents for Peer Review and
Management Approval
1. Save a copy of the Audit Folder Route Form from the SURS Documentation panel; this document is called “Audit Folder Route Form”.
2. Enter the Audit Case Number.
a. If the documents are for a bulk audit, enter the Bulk ID.
3. In the Date Initiated field:
MARS: Enter the date the audit was initiated (this is the Physical Audit Start Date in SURS).
PARS: Enter the date the case is routed for Peer Review.
4. From the “Type of Letter” dropdown, select the type of letter (i.e. Notice of Intent to Recover, Preliminary Findings).
a. For bulk audits: i. Leave this field blank and write the number of letters per letter type (i.e. 5
Prelim, 1 No Findings), or ii. Leave this field blank. In the “Quantity” column at the bottom of the form,
enter the total number of letters in the “Letter” row. In the “Other” field in the Forms section, indicate the number of letters per letter type.
5. Enter the provider name.
a. If the documents are for a bulk audit, enter “Various”.
6. In the “Provider/Recipient #” field, enter the provider’s Medicaid ID and National Provider Identifier (NPI).
a. If the documents are for a bulk audit, enter “Various”.
7. In the Background Statement:
MARS: Include the following: o Provider type o Brief description of reason for audit (i.e. complaint based, re-audit) o Scope o Provider certification date o Total reimbursement for audit scope o How records were obtained (only if unusual)
PARS: Enter a summary of the type and focus of the audit, as well as a brief description of the identified findings.
Example: Pharmacy – Injectable Drug audit. Findings are for billing in excess of services provided, failing to bill recipients’ other insurance, and lack of documentation.
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Note: If the documents being routed are for Amended Preliminary Findings or NIR, indicate if there was a change in the recoupment amount.
8. Enter the recoupment amount. a. If the documents are for a bulk audit, enter the total recoupment amount for all
providers in the audit.
9. Fill in the Lead Auditor name.
10. From the “Select Section Chief” dropdown, select the name of the appropriate Section Chief. 11. In the “Mailed” column, select “Yes” or “No” for each document type to indicate if the
document should be mailed. a. If the document is not applicable to the audit (i.e. no TA reports were produced),
select “N/A”.
12. In the “Quantity” column, enter how many of each type of document is included in the folder or in the case.
13. MARS: In the “Forms” column, if a Complaint Report was requested for the audit, indicate if all of the complaint issues could be addressed by the audit-related activity.
14. If the audit is a bulk audit, create a bulk audit summary report that includes information like the following:
Bulk ID
Case ID
Provider ID
Provider Name
Audit Stage
Projected Recoup
Final Recoup (this will be blank at the Preliminary Findings stage)
A sample template is located at L: > Oig Ma > Auditor > Bulk Audit Summary Report Template. Place this summary report in the routing folder.
15. Route the case for peer review (see “Peer Review” section).
16. Once the case has passed peer review (as indicated by the Peer Reviewer’s initials), the auditor will initial in the Auditor column.
17. If an Exit Conference is needed (refer to the “Exit Conferences with Providers” section): a. On the Audit Folder Route Form, select “Yes” next to “Exit Conference Needed?”
at the top of the form. b. Follow the instructions in the “Exit Conferences with Providers” section.
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18. If there is anything particular about the case that impacts the mailing of the audit letter(s) and
report(s), staple instructions on top of the routing form. Do not use a sticky note, as that can detach.
PARS: Instead of stapling instructions to Admin to the routing form, include instructions in the Background Statement.
19. Attach the Audit Folder Route Form to the folder. Give the folder to the appropriate audit supervisor.
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Peer Review Before audit folders are given to the supervisors, they should be reviewed by a peer reviewer for completeness and accuracy. Peer reviews are required for most audit types. Audits of Electronic Health Record (EHR), Federally Qualified Health Centers (FQHC), and Rural Health Centers (RHC) are excluded from the process. The following guide describes how peer reviews are assigned and the process peer reviewers should follow.
MARS: If, during the peer review process, the peer reviewer notices anything odd or is trying to make sense of the findings, the peer reviewer may review documents from the audit in the audit file on the L: drive or ask the auditor for some of the documents in order to verify that the auditor conducted the audit correctly. PARS: For new auditors, or auditors new to the audit type, a peer reviewer will review a sample of three to five recipient files to ensure the auditor has an understanding of the audit. The exchange of information will follow the process steps described below.
ASSIGNING PEER REVIEWS
The supervisors will assign the peer reviewer while developing the schedule. Each audit on the schedule has a peer reviewer identified that is responsible for the peer review at all stages of the audit process.
PEER REVIEW CHECKLISTS
Both MARS and PARS have peer review checklists available in the Documentation panel in SURS. Peer review checklists may also be required as part of a Performance Improvement Plan (PIP).
MARS: All peer reviewers must use the peer review checklists.
PARS: Experienced peer reviewers are generally not required to use the peer review checklist, but can use the checklist if they so choose. New auditors are required to use the peer review checklist pending demonstrated competence.
All peer review checklists, whether required or optional, must be completed electronically and saved in the appropriate folder on the L: drive (refer to Step 1 in the “Completing Peer Reviews” subsection).
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COMPLETING PEER REVIEWS
1. The auditor will save the documents to be peer reviewed in the appropriate location on the L: drive. Nothing should be uploaded to SURS prior to the completion of the peer review. MARS: The auditor will place the following documents in the MARS Peer Review folder located at L: > Oig Ma > Audit Programs > [Audit Type] > [Provider Name] [Case Number] > [Audit Stage] > Peer Review
All reports
Letter
Audit plans (included in the peer review for the Preliminary Findings stage only)
Narrative findings
Audit folder route form
Technical Assistance Reports (when applicable)
The documents will be named in the following format: [# of round of peer review][date document is being saved][SURS-assigned document name]. For example, if an External Report is being sent through peer review for the first time, and the document is being saved on April 1, 2018, the naming convention would be: 1 04012018 External_Rpt_20180401_0711 If the report needs to be corrected and sent through peer review again the next day, the naming convention would be: 2 04022018 External_Rpt_20180402_0823 PARS:
Each audit has an individual folder in the L: drive. (L: Oig Ma Auditor AA_PARS Peer
Review (Auditor’s Name) (Case number/provider name). Once the auditor completes the audit, they should upload the following documents to the L: drive:
All reports
Letter
Audit plans
Narrative findings
Audit folder route form
Technical Assistance Reports (when applicable)
MFCU referral (when applicable)
Folders in the AA_PARS Peer Review folder should be structured and named in such a way that a peer reviewer can easily locate documents. Documents should be named in a manner that the peer reviewer can easily identify the document without having to open it.
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The following is an example of a folder layout:
o Auditor name o Bulk # and audit focus (i.e. B123456789 Compression Garments)
Individual Case ID# and Provider Name
Narrative Findings
NIR letter
Summary
External or Detail Report
2. The auditor will email the peer reviewer to let them know the audit is ready to review, or give the routing folder to the peer reviewer. The auditor should include the summary when it is a bulk audit.
3. The peer reviewer completes the review, including communicating required corrections,
electronically through adding comments and highlighting on the PDF documents. The peer reviewer will not edit any of the documents’ contents. To add comments to a PDF document, the peer reviewer should determine the version of Adobe Reader on their computer (by selecting the Start icon in the bottom left corner of the computer screen and searching for Adobe or Acrobat Reader), then use an internet search to determine the steps for adding comments. If the version of Adobe does not appear to allow a user to add comments, contact Tech Support for assistance.
4. The peer reviewer saves the corrected document in the appropriate folder on the L: drive (refer to
Step 1) and notifies the auditor via the following methods: MARS: Return the routing folder to the auditor. PARS: Return the routing folder to the auditor or notify the auditor via e-mail.
5. The auditor makes the required corrections, saves as a new document (see Step 1) and notifies the peer reviewer the audit is ready to be re-checked. For PDF documents with comments, users can enter a checkmark in the Comment List indicating if an error has been addressed.
6. MARS: The peer reviewer confirms the auditor has made the corrections. PARS: Optional: The peer reviewer confirms the auditor has made the corrections.
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7. The peer reviewer writes their initials and their approval date on the Audit Folder Route Form, then returns the folder to the auditor. The auditor will route the case for management review (refer to “Routing Audit Documents for Peer Review and Management Approval” instructions). MARS:
Documents will not be uploaded into SURS until the auditor has been notified by the supervisor. Nothing should be uploaded to SURS prior to the completion of the peer review and supervisor review.
Documents should be named in a manner that the peer reviewer and supervisors can easily identify the document without having to open it.
PARS:
All documents must be uploaded to SURS prior to routing the folder to the supervisors.
PEER REVIEW L: DRIVE MAINTENANCE
After Admin mails the letter(s), auditors are responsible for deleting all documents for peer review from the L: drive.
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Document Approval in SURS Audit letters and reports are reviewed and approved in SURS through the following levels of management.
Audit Supervisor
Section Chief
Deputy Inspector General
Inspector General
Once audit letters and reports are approved, Admin mails them to providers.
Exit Conferences with Providers For certain audit types, auditors will conduct an exit conference with the provider before the Preliminary Findings documents are sent to the provider. This is done to explain the audit process and audit findings to the provider, to make sure the provider understands how to read our reports and to answer the provider’s questions. Refer to the corresponding audit guides located at L: > Oig Ma > Auditor > Audit Procedures or ask the appropriate supervisor to determine if the audit type will require an exit conference. The auditor should review the notes in the prior audit cases of the provider to determine whether or not an exit conference was completed previously. If the provider participated in an exit conference during a previous audit, exit conferences are usually not required for subsequent audits; however the auditor should discuss with their supervisor and/or section chief as to whether or not one should be completed.
PREPARING FOR THE EXIT CONFERENCE
1. Route the Preliminary Findings letter and corresponding documentation. When routing the
Preliminary Findings letter: a. On the Audit Folder Route Form, select “Yes” next to “Exit Conference Needed?”
at the top of the form. b. Highlight the checked box. c. Ask Admin to not to send out the Preliminary Findings letter until after the exit
conference has been conducted. Admin will return the auditor folder once the Inspector General approves the letters and reports.
2. When the folder is approved by OIG management and returned, gather the following
information:
A copy of these Exit Conference steps
A copy of the Preliminary Findings letter
A copy of pages from the External Report. o MARS: Send pages of the report that demonstrate different examples of
how to read the report (i.e. a page with one finding, a page with a finding that covers a range of dates, a page with a claim that has multiple findings)
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o PARS: Send the first 3 or 4 pages of the External Report
A copy of the Summary Report
A copy of the Narrative Findings
A copy of one Technical Assistance Report (if applicable)
3. Select a second auditor (or ask a supervisor for assistance in selecting a second auditor) to take notes during the exit conference. The auditor taking notes will fill out the “Exit Conference” document located in the SURS Documentation panel (the document is called “Exit Conference”; MARS and PARS each have a distinct template). Confirm potential conference call times with that auditor.
4. Call the provider, identify yourself, tell the provider the audit has been completed and that
you would like to fax over a sample of the audit report and set up a conference call to go over the report. Tell the provider the purpose of the conference is to make sure he/she understands how to read the report and what the next steps are. Get a fax number and set up a conference call time.
5. About 30 minutes prior to the start of the conference call, fill out a fax cover sheet and fax
over the documents compiled in Step 2, with the exception of the exit conference steps. 6. Bring the fax and a copy of the exit conference steps to the conference call. 7. Conduct the conference call with a fellow auditor taking notes.
CONDUCTING THE EXIT CONFERENCE
Things to Keep in Mind
You run the exit conference, not the provider. Stay on target.
Listen to the provider’s concerns/questions and help out where you can. If the provider becomes repetitive, too detailed or is generally making the process more difficult than it needs to be, tell the provider to put his/her response in writing and submit it with the appropriate supporting documentation.
The provider may ask about payment plans. Payment plans need to be submitted in writing (faxing is fine) to you and you will forward the request to management for approval. You will call the provider after management makes a decision.
Should the provider become verbally abusive (swearing at you, name calling, etc.), tell the provider that swearing and name calling are unacceptable that you will end the exit conference if the provider continues. If the provider does it again, tell them that you are ending the conference call and hang up.
1. Introduce yourself, including your job title and that you work for the Office of the Inspector General (OIG). Introduce the auditor, or other staff member, who is taking notes.
2. Ask the provider to identify themselves and anyone else who is participating on the call.
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3. Tell the provider the purpose of the exit conference is to explain the audit process and make sure he/she understands how to read the audit report.
a. If the provider has a legal representative with them, be mindful of any questions that the legal representative asks. If you feel the questions are outside the scope of the audit or are about the interpretation of Wisconsin Administrative Code, federal regulations, etc., tell the legal representative that the provider will have a chance to submit rebuttal to the Preliminary Findings letter and can also file an appeal in response to an NIR letter.
4. Explain the audit process:
Record request is sent or records are picked up onsite.
Auditor reviews records.
Preliminary Findings. Explain that this letter identifies the audit type, scope, and preliminary recoupment amount. Emphasize the findings are preliminary and subject to the provider’s response. Point out the address to submit payment and the address at the top of the page to submit documentation. Explain that your phone and fax number will be at the end of the letter that the provider will be receiving.
Narrative Findings/Record of an Audit Finding. Explain that this document lists the type of audit finding and provides the appropriate Administrative Code and Handbook citations to support the recoupment.
Summary Report. Read through the report with the provider to ensure he/she understands the format.
External Report. Read through the report with the provider to ensure he/she understands the format. Identify the finding, date, procedure code, modifiers, definition, quantity allowed, disallowed, billed, paid and potential recoupment. Remind the provider to look at the complete finding and to respond to all of issues noted in the comment.
Technical Assistance Reports. Mention these are to be used as educational tools.
5. Explain what happens next:
Response time The provider has 30 days from the date he or she receives the Preliminary Findings letter to submit rebuttal documentation. Tell the provider to call you at any time with questions related to the audit or rebuttal. If the provider needs an extension to submit rebuttal documentation, tell the provider to submit the extension request in writing via fax or email (Note: auditors may grant up to a two-week extension for providers to submit rebuttal. Requests longer than two weeks, or subsequent requests for additional time, require management approval). The request itself will need to be in writing and approval is a management decision. If the provider agrees with the findings and wants to submit payment, let them know the payment address is listed in the Preliminary Findings letter.
Rebuttal The rebuttal documentation should be in response to the initial finding and any other findings listed in the comment section. Tell the provider to read the entire comment as there may be more than one finding to respond to. Remind the
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provider that all findings on the claim detail must be addressed and overturned in order for that claim detail to be made payable. Ask the provider to use a specific format to respond. Ask that the format chosen be self-explanatory and that it can be easily followed. Also ask the provider to indicate which findings he/she agrees with.
Notice of Intent to Recover (NIR) If the provider does not submit payment, an NIR letter will be sent. Tell the provider to follow directions given in the NIR. The NIR gives the provider 20 calendar days to request an appeal and gives the address to submit the appeal. Tell the provider NOT to submit his/her request for a hearing to OIG; per the NIR, it should be sent to the Division of Hearings and Appeals. Tell the provider to read the information in the NIR letter carefully as it is time sensitive. If the provider does not appeal and does not submit payment, the recoupment amount will be withheld from future remittances.
6. Thank the provider for participating in the exit conference. 7. Once the call is completed, the auditor who took notes will type up the notes using the Exit
Conference form in the Documentation panel in SURS (the document is named “Exit Conference”). Once completed, the auditor will send the notes to the lead auditor to upload to the case in SURS.
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Providers Wanting to Return Overpayments If a provider receives a Preliminary Findings letter or an Amended Preliminary Findings letter (along with an audit report that indicates an overpayment amount), the auditor will respond using the scenarios described in Appendix C: Provider Payment at Prelim/Amended Prelim Scenarios.
Rebuttal Documentation
1. Receive the provider’s rebuttal documentation. a. If the documentation is submitted via mail:
MARS: Date stamp every page of the rebuttal documentation (to distinguish the rebuttal documentation from the original audit documentation).
PARS: Date stamp the first page of the rebuttal documentation.
2. Review the provider’s rebuttal documentation and determine what the next audit stage should be (refer to the “Audit Letters” section in Chapter 2 for more information; the letter name reflects the stage of the audit).
a. If the provider did not submit rebuttal documentation, see if the provider submitted payment in response to the Preliminary Findings letter (refer to the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures). If the provider did not submit payment, issue an NIR-No Response letter.
3. In SURS, confirm that the case has advanced to the correct audit stage. a. Access the case in SURS. b. In the Case Information Maintenance subpanel, select Audit Details. c. Review the Audit Stage.
i. If the Audit Stage is NIR and the stage should be Amended Prelim, refer to the “Changing Case to Amended Prelim Status” in the SURS User Guide (located at L: > Oig Ma > Auditor > Audit Procedures).
a.) The “dummy” Amended Prelim letter can be deleted and a new Amended Prelim letter generated so long as no changes are made to the findings between the time when the “dummy” letter is deleted and the new letter is generated, or
b.) The “dummy” Amended Prelim letter can be filled out with the correct information (findings information, overpayment amount, etc.) and used as the actual Amended Prelim letter to be mailed.
4. Enter rebuttal comments into SURS or whichever program (Microsoft Access, Excel, etc.) the
preliminary findings were entered (refer to audit-specific training guides for more information). Note: If the comments were entered in the wrong stage (i.e. the audit stage is NIR but should be Amended Prelim), ask management about who should be contacted to correct the audit stage. Do not attempt to change the audit stage by generating a “dummy” letter and reentering comments.
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5. If an ICN had a preliminary finding and the claim was adjusted (refer to the “Claim Adjustments” section):
a. In the SURS Audit Findings panel, change the Recoup Amount to $0. b. If the claim is in a pharmacy audit, select the “CLAIM ADJUSTED” finding. c. Enter a rebuttal comment in the SURS Finding Comment field explaining that OIG
will not be recouping the claim because it was adjusted. List the adjusted “daughter” ICN in the comment.
6. If findings remain, generate a Rebuttal Detail Report and Rebuttal Summary Report in SURS, or
generate equivalent reports in whatever program (Microsoft Access, Excel, etc.) the preliminary findings were entered (refer to audit-specific training guides for more information).
7. Generate the appropriate letter in SURS (refer to the “Audit Letters” section in Chapter 2). 8. If the audit was a bulk audit, complete the bulk audit summary routing checklist (produced during
the Preliminary Findings stage) by filling in the “Final Recoup” column.
9. Upload documents to the appropriate Peer Review folder (see the “Peer Review” instructions).
10. Once the Peer Review process is complete, route documents for review and approval (see “Routing Audit Documents for Approval” instructions).
Note: Once a provider receives the NIR letter, they have 20 calendar days to file an appeal with the Division of Hearings and Appeals (DHA) or 30 calendar days to submit payment to the Cash Unit. If an appeal is not filed and the provider does not submit payment, the overpayment amount will be recouped from future Medicaid remittances.
Undeliverable NIR/Provider Refuses NIR Per DHS 108.02 (9) (b), final notices of intent to recover shall be sent by certified mail. The NIR gives the provider the recoupment amount, the remittance address to submit payment, and the mailing address for the Division of Hearings and Appeals if the provider wants to file an appeal within 20 calendar days from the date they receive the NIR. If the NIR is returned to the OIG as undeliverable or if the NIR is refused by the provider:
1. Call the provider to verify the mailing address. 2. If the provider says they have a different mailing address, email administrative staff
requesting that they re-send the NIR via certified mail to the new address. 3. If the provider cannot be reached via phone, email administrative staff requesting that they
re-send the NIR to the original address via both certified mail and first class postage. a. If the second certified letter and the first class postage letter are returned
undeliverable: i. Scan the returned mail and upload it to the audit case.
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ii. Generate and route a Financial Transaction form (refer to the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions).
b. If only the second certified letter is returned undeliverable, not the first class postage letter, and the provider does not submit payment within 30 days of first class postage mail date:
i. Scan the returned mail and upload it to the audit case. ii. Generate and route a Financial Transaction form.
Recoupments (Financial Transaction Forms) If a provider does not submit payment within 45 days of receiving an NIR letter and the provider does not file an appeal, the auditor will fill out a Financial Transaction form following the instructions in the Financial Transaction Guide (located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions).
Provider Communication
PHONE CONVERSATIONS
Communication with providers must be professional, courteous and non-threatening. Auditors should follow these guidelines when speaking with providers:
Listen to the provider’s concerns and questions and help out where you can. If, however, a provider becomes repetitive, off target or is generally making the conversation more difficult than it needs to be, take control of the conversation. Reiterate the provider’s concern so he or she knows you understand the issue and tell the provider what the next step is for him or her to resolve that issue. Probable next steps for the provider would be one of the following:
Submitting rebuttal documentation
Filing an appeal
Contacting Wisconsin Medicaid Provider Services (if the provider has billing questions)
Should the provider become verbally abusive (swearing, name calling, etc.), tell the provider that swearing and name calling are not acceptable and that you will end the conversation if the providers continues. If the provider does it again, tell them that you are ending the conversation and hang up.
Document with whom you spoke, along with the date, time and content of your phone call.
MARS: Keep an electronic copy of the document in the Communications or Phone Records subfolder in the audit file (refer to “Audit Documentation” section in Chapter 2).
PARS: Keep an electronic copy of the document in the audit folder you created for the audit on your H: drive.
When closing the case, always upload a copy of the document to the audit in Case Tracker.
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WRITTEN CORRESPONDENCE
Most written correspondence with providers will be done via standard letters from Case Tracker and will not require changes from the auditor. There are times that the auditor will be required to add language to letters, such as when a provider submits payment for some of the audit findings at the Preliminary Findings stage of the audit but still has findings at the NIR stage. Auditors should check with an audit supervisor or a co-worker if they need help with phrasing.
If auditors correspond with a provider regarding an audit via email, the auditor will maintain a professional, courteous and non-threatening tone. Information given in the email should be clear and accurate. Keep in mind the email could later be used as part of an appeal or be part of an open records request from the media. Auditors must retain all email correspondence with providers and upload the correspondence to the SURS case. To convert all email correspondence into a single .pdf document:
1. Place all the relevant emails into a single Outlook folder.
2. Highlight all the emails.
3. Select File.
4. Select Print.
5. From the Printer dropdown, select CutePDF Writer.
6. Select Print.
7. Save the document in the appropriate location (refer to the “Phone Conversations” section).
8. When closing the case, upload the document into the documentation panel in SURS.
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Provider Appeals Many provider appeals are filed because the provider needs time to submit documentation in response to the audit. This typically happens when the provider does not respond to the preliminary findings letter and an NIR is issued. Strict time limits are in place once the NIR is issued, so the provider files an appeal to stop the recoupment process.
If a provider files an appeal, the auditor will be cc’d on a letter from the Division of Hearings and Appeals (DHA) acknowledging the receipt of the provider’s request for a hearing. OLC is also cc’d on this letter and a lawyer from OLC will be assigned to the case. The auditor will receive the following email from a paralegal in OLC:
We have received the appeal in the above matter. Attorney [OLC attorney’s name] has been assigned. Please contact the provider to determine if the contested issues can be resolved without the need for a hearing. Your contact to the provider should include an explicit request for any additional documentation the provider wants you to consider. This contact needs to be documented in your file in the event the case goes to hearing and we are required to show the ALJ that we have given the provider additional opportunities to state their position.
Should you feel more than 60 days will be needed, please contact me and I will request an extension from DHA. Once you have reached resolution or determined that the appeal cannot be resolved, notify me so we can determine what course of action to take.
The above email from OLC is sent to the auditor to acknowledge the appeal and to ask the auditor to attempt to resolve the matter with the provider before the case is brought before an Administrative Law Judge (ALJ).
1. Call or e-mail the provider and ask the following:
Do you have any additional documentation to submit to OIG for review?
Do you have legal representation?
If a provider indicates they have legal representation, contact the OLC attorney for guidance on how to proceed. If a third party contacts the auditor claiming to be the provider’s legal representative, the auditor will contact the provider and ask for written confirmation as to the identify of their legal representative. If communicating with the provider or their legal representative via phone, keep a detailed log describing the phone call. If communicating via email, the e-mail should be specific and detailed. All correspondence will be used by OLC in the hearing; therefore, it will be important that OIG requests for documentation and provider contact throughout the audit are well documented. Note: A provider may have legal representation for other Medicaid-related matters (i.e. suspension) but not for the audit appeal. The auditor may communicate directly with the provider about the audit appeal, but should notify OLC as well.
2. Reply to the e-mail from OLC’s paralegal. Let the paralegal know what the course of action is. Indicate if you believe you will be able to work the appeal out with the provider.
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Note: There will be times that the auditor has already worked with the provider throughout the Preliminary Findings stage of the audit and the auditor and provider already reach an impasse, so the provider files an appeal. If an appeal is filed for this reason and there isn’t anything more the auditor can do to work with the provider, respond to the above email indicating the issues will not be resolved without a hearing and there is no need to wait 60 days.
3. If the provider submits rebuttal documentation, review the documentation. a. If the documentation reverses all findings ($0 recoupment):
i. Send an Amended NIR letter and an adjusted recoupment report to the provider. ii. Forward the provider’s information to the paralegal and ask the paralegal to send
the provider information on how to withdraw their appeal. Do not give the provider the paralegal’s contact information.
iii. Once the provider withdraws the appeal, OLC will forward the dismissal order from DHA.
b. If the documentation reverses some but not all findings, and the provider agrees with the new recoupment amount and wants to withdraw the appeal:
i. Send an Amended NIR and an adjusted recoupment report to the provider. ii. Forward the provider’s information to the paralegal and ask the paralegal to send
the provider information on how to withdraw their appeal. Do not give the provider the paralegal’s contact information.
iii. Once the provider withdraws the appeal, OLC will forward the dismissal order from DHA. Once the auditor receives this dismissal, the auditor will route a Financial Transaction form (see the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions for more information).
c. If the documentation reverses some but not all findings, but the provider disagrees with the new recoupment amount and wants to pursue the appeal, notify the OLC attorney of the change in the recoupment amount and ask how they would like to proceed.
4. If the provider proposes a settlement amount: a. Ask the provider for a breakdown of the settlement amount (i.e. which claims the
settlement amount applies to and how much per claim). b. Email the proposal to the Section Chief (and cc the appropriate audit supervisor). The
Section Chief will discuss the settlement with the Inspector General and Deputy Inspector General. The Section Chief will notify the auditor the outcome of this discussion via email. The auditor will save a copy of this email to the case.
i. If the settlement amount is accepted: a.) Notify the OLC attorney and ask them to draft a settlement agreement. b.) Review the settlement agreement for accuracy. c.) Obtain the Inspector General’s signature and return the agreement to the
attorney. The attorney will forward it to the provider for their signature. d.) Once the attorney receives the signed agreement from the provider, the
attorney will draft a Settlement Agreement & Stipulation of Dismissal. The attorney will submit this document to DHA and request that the appeal be closed. OLC will email a copy of this document to the auditor.
e.) Upload the Settlement Agreement & Stipulation of Dismissal to the case.
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f.) Email a copy to the Cash Unit of the Department’s fiscal agent. The Cash Unit will set up an A/R based on the amount in the Settlement Agreement.
i.) If the provider submits payment within the timeframe specified in the Settlement Agreement, the payment will be applied to the A/R.
ii.) If the provider does not submit payment, the A/R will recoup the amount from the provider’s remittances.
ii. If the settlement amount is not accepted: a.) Notify the provider. b.) Proceed to Step 5.
Note: Sometimes the provider will propose a settlement to the OLC attorney instead of the auditor. The attorney may contact the Section Chief, Deputy Inspector General, or Inspector General instead of notifying the auditor. If the auditor is unsure if a settlement proposal was routed through OLC to OIG, the auditor should contact the OLC attorney.
5. If the provider proposes a payment plan, refer to the “Payment Plans/Promissory Notes” section
of the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions. When the provider signs and returns the Promissory Note, provide a copy to the OLC attorney so OLC can notify DHA that the provider wishes to withdraw the appeal.
6. If the auditor and the provider cannot come to an agreement within 60 days after the appeal is
filed and it is unlikely the auditor and the provider will come to an agreement, notify the OLC attorney. The attorney will contact the auditor and guide them through the remainder of the appeal process.
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ADMINISTRATIVE HEARINGS
The OLC attorney will assist the auditor with preparing for the hearing. The auditor should also refer to OLC’s Testifying Tips, which can be accessed at https://dhsworkweb.wisconsin.gov/olc/testifying-tips.htm or by the following:
1. Access the DHS WorkWeb page (https://dhsworkweb.wisconsin.gov/).
2. From the Executive Offices dropdown, select 1 West Wilson.
3. Under the Executive Offices menu, select Office of Legal Counsel.
4. Select Testifying Tips.
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Auditors should also refer to the “Preparing to Testify” tips. After the hearing, the ALJ will issue a decision.
1. If the decision is favorable to the Department, the auditor should review the decision to see if it is a Proposed or Final Decision.
a. If it is a Proposed Decision, wait until the Final Decision is issued before continuing to Step 1 b.
b. If it is a Final Hearing: i. Wait at least 30 days (in case the provider appeals the decision with a circuit
court). ii. Refer to the Financial Transaction Guide located at L: > Oig Ma > Auditor >
Audit Procedures > Financial Transactions to determine what action to take for the recoupment.
iii. Close the audit.
2. If the decision is favorable to the provider, the auditor should review the decision to see if it is a Proposed or Final Decision.
a. If it is a Proposed Decision, wait until the Final Decision is issued before continuing to Step 2 b.
b. If it is a Final Decision: i. Wait at least 30 days (in case OLC appeals the decision with a circuit court). ii. Close the audit.
3. If the decision favors the Department for certain findings and also favors the providers for other
findings, confer with OIG management and OLC on the next appropriate step(s).
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PREPARING TO TESTIFY
(Provided by OLC during OLC/OIG meeting on 9/26/2016)
1. Always tell the truth.
2. There is nothing unethical about preparing to testify by working with OLC attorneys. If you are asked whether you discussed your testimony with anyone before the hearing, your answer is: “YES, I spoke with Attorney__________from OLC.”
3. If you are asked a question that you do not understand, then say so.
You cannot tell the truth if you do not understand the question.
You cannot tell the truth if you “guess.”
If you do not understand the question, it is likely the ALJ will not either.
4. When you do not know the answer to a question be clear in your response:
If you knew once but have forgotten – “I don’t remember.” i. This allows a follow-up question – “Is the answer in your records or notes?”
If you never knew – “I don’t know.” i. Don’t guess (it would be untruthful.) ii. If you guess wrong, it looks like you don’t know what you are doing.
5. Just answer the question that is asked, don’t expound or explain.
If the question calls for a yes or no answer, then there are four acceptable answers: i. Yes – (Not yup, yeah, or unhuh) ii. No – (Not nope, naw, nay or unhuh) iii. I don’t know. iv. I don’t remember.
6. Ask for the question to be restated if:
It is a compound question (especially if the answer to one part is Yes but the answer to the second part is No.)
If the question is based upon a false premise: i. For example: “Since there is no requirement for PCWs to keep timesheets,
why are you requiring the Nurse’s documentation of the supervisory visit to show the time of the visit?”
ii. Have you stopped beating your spouse yet? (The underlying premise is that you have in past beast your spouse.)
7. Silence is okay. Do not feel the need to fill the pregnant pauses between your answer and the next question. As long as you keep talking the opposing counsel is likely to let you, hoping that you will say something he/she can catch you on.
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8. If there is an Objection raised, stop talking immediately until you are instructed to answer the
question. You may want to have the question repeated before you answer.
9. Speak up, the hearing is being audio recorded. Also be mindful of items or actions that might
create unnecessary noise (clinking bracelets, tapping on the table, etc.).
10. Speak clearly, the hearing is being audio recorded.
11. The ALJ is your audience, so look at the ALJ when answering the question.
12. Don’t anticipate where the question is going, listen to the whole question before you answer.
13. Sometimes there are questions that may need further explanation or qualification; the OLC
attorney will decide whether to ask follow-up questions on redirect examination.
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Closing the Audit
Once an audit is completed and the auditor has verified that the Accounts Receivable (A/R) has been set up in iC2, if applicable,(refer to the Financial Transaction Guide located at L: > Oig Ma > Auditor > Audit Procedures > Financial Transactions), the auditor must complete an Audit Summary Letter. The A/R does not have to be fully recouped in order for the audit to be closed; however, MARS auditors generally wait until the first monthly payment has been applied to the A/R before closing the audit.
If this is a bulk audit, an Audit Summary Letter will be completed for one case and then uploaded to the Documentation panel of the other cases in the same bulk. For bulk audits, include a Case Summary sheet listing all of the case numbers, provider ID numbers, provider names, final recoupment amounts, and corresponding A/R for each of the individual cases; the Case Summary sheet should then be uploaded to the Documentation panel of the other cases in the same bulk.
1. Access the case. 2. In the Documentation panel, make sure all documentation pertaining to the audit has been
uploaded. This includes (but is not limited to) records from the provider, regardless of how those records were submitted to OIG. If documentation has not been uploaded, do so before creating or routing the Audit Summary Letter. Notes:
Files should be named in such a way as to indicate the files’ contents. o If the file contains documentation for multiple members, use “Member
Files” in the file name. o If each file contains documentation for a single member, use “Member Files,
[Member Last Name]” in the file name. o If there are multiple files that have the same name, add “1”, “2”, etc. to the
end of each file.
Files cannot be larger than 20 megabytes (MB); however, multiple files up to this size can be uploaded into the case.
When uploading a file into the Documentation panel of the case, the Comment section (see below) can be used to add pertinent details about the file’s contents (i.e. provider’s initial records, rebuttal documentation).
If there are materials that were submitted by the provider that cannot be uploaded, send those materials to the records center (see Step 15).
If an auditor experiences issues with uploading a file into SURS, they should notify management.
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3. In the Case Information Maintenance panel, select Letters. 4. From the Name of Letter dropdown, select Audit Summary Letter. 5. Select enter. The Audit Summary Letter draft will appear. 6. Select (T)okens. The following tokens should auto-populate:
Provider_Name
Provider_Number
Projected_Recovery
Auditor_Name
Approving_Supervisor_Name
a. In the Auditor_Approved_Date field, enter the letter create date. b. If the Audit Summary Letter is for a bulk audit:
i. In the Provider_Name field, enter “Various”. ii. In the Provider_Number field, enter “Various”. iii. In the Projected_Recovery field, enter the total recovery amount for all the
cases in the bulk.
7. Select Accept.
8. Select (M)erge.
9. In the AR# field: a. For a single-provider audit, enter the AR# from iC2. b. For a bulk audit, enter “Various”.
10. Fill out the CASE SUMMARY section. The section must contain at least three paragraphs
with the wording indicated below. Auditors may add to the paragraphs, but the following information must be included at a minimum.
a. For a single-provider audit:
Paragraph One: The OIG’s review found that this provider was not in compliance with the Wisconsin Medicaid regulations concerning the billing for [list audit type] for the time period of [list scope].
o If the audit resulted in a No Findings letter, Paragraph One should indicate the provider would found to be in compliance.
Paragraph Two: This provider was audited by [list provider name] and found to have overpayments. The overpayments were from billing for [list reasons recouped]. (Next, write a brief summary of the audit progression. Include dates of letters, recoup amounts, if rebuttal was received, if appeal was filed, was A/R set up or did provider pay, etc.).
o If the audit resulted in a No Findings letter, Paragraph Two should indicate that no overpayments were found.
Paragraph Three (two sentences only): o Sentence 1: (Choose the appropriate option listed below)
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The receivable has been set up for this overpayment.
The provider submitted payment.
The provider submitted partial payment and a receivable has been set up for the balance owed.
The auditor reviewed the records and found no overpayment. o Sentence 2: It is recommended that this case be closed with no
further action by the OIG.
b. For a bulk audit, follow the format for a single-provider audit. Change the language to indicate how many providers were audited, what the total overpayment amount for all cases was, how many providers submitted rebuttal, etc.
11. In the RECORD LOCATION section, select either Documentation sent to Records
Center or Documentation Uploaded to Case. a. To select an option:
i. Right-click the appropriate box. A menu will appear. ii. From the menu, select Checkbox Properties.
iii. In the Checkbox Properties box, select Selected.
iv. Select OK.
Notes:
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If the “Documentation sent to Records Center” option is selected, Admin will fill in the Box Number.
If the audit has files that were uploaded into SURS and also has materials that will be sent to the Records Center because they could not be uploaded into SURS, select both the “Documentation sent to Records Center” and the “Documentation Uploaded to Case” options.
12. Select Preview and review the letter.
13. Select (A)pprove. a. For a single-provider audit, proceed to Step 13. b. For a bulk audit:
i. Save a copy of the Audit Summary Letter. ii. Upload a copy into the Documentation panel for each case within the same
bulk. iii. For each uploaded copy, enter the comment “The approved letter is in case
#_________.” iv. Upload the Case Summary Sheet (that includes all the A/Rs) to all audits in
the bulk.
14. The Audit Summary Letter will appear on the supervisor’s landing page. Auditors may email their supervisor to let them know the Audit Summary Letter has been routed to them, but this is not required.
15. Once the supervisor approves the Audit Summary Letter, gather any materials that could not
be scanned into SURS. The auditor should email the appropriate Admin staff letting them know the auditor will be bringing over audit documentation. Admin staff will send the documentation to the record center to be stored.
16. Auditors should review their home page in SURS to ensure all the cases submitted to Admin for closing were in fact closed and came off their landing pages.
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Paper Record Destruction Due to the approval of Record Disposition Authorization (RDA)-00404 in September 2018, the Office of the Inspector General may retain an electronic copy of all paper records received in lieu of keeping the hard copies of the submitted records. Staff must follow these steps to be compliant with RDA-00404.
Key points to remember:
1. This RDA only applies to records submitted to OIG on paper.
2. Auditors must verify the quality of the uploaded records by opening the scanned documents and confirming the following:
a. All pages of the document were scanned – both sides of double-sided pages are present
b. The documents are legible c. The documents are straight and none are cut off
3. Auditors must wait 30 days after the date the records are scanned and uploaded into SURS
before the records can be destroyed.
4. Auditors must place the records in an appropriate bin designated for shredding. If the bin(s) are full, there are instructions on top of the bin that provide a number to call for additional bins.
5. Auditors must enter the following dates in the Comments section in the appropriate SURS
case:
Date the records were scanned and uploaded into SURS
Date the auditor verified the quality of the records in SURS
Date the records were placed in the appropriate bin designed for shredding
6. The above applies to records received and scanned to the case before the RDA was approved, so long as the three dates specified above are entered in the Comments section in SURS. Once 30 days have passed from when the records were scanned and uploaded to the case, the records may be destroyed.
7. Any OIG personnel can scan the records, but that personnel must enter the appropriate dates in the SURS case.
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8. Prior to closing a case, auditors are ultimately responsible for ensuring that the quality of the records is verified, that the 30 days have passed before disposing of paper records, and the appropriate dates are entered in the Comments section.
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Fraud Referrals
Medicaid Fraud Control and Elder Abuse Unit (MFCEAU) The auditor will refer a provider to the MFCEAU if they suspect fraudulent practices. The purpose of this guideline is to provide written instruction for completing and routing a MFCEAU referral. PROCESS
I. Prior to Creating a Referral A. Complete the review of the audit documentation to be sure all instances of possible
fraud have been reviewed. B. Schedule a meeting with the appropriate supervisor and section chief. This meeting
should determine: 1. If and at what stage in the audit process a referral should be made 2. What information will be included in the referral 3. The content and order of the exhibits
II. Creating a Referral Cover Sheet A. Access the MFCEAU template in the main documentation panel in Case Tracker. B. Complete all sections on the cover sheet with the specific provider information:
1. Complaint Information a. This information will be located in the case specific complaint panel
in Case Tracker. b. If the referral is not based on a complaint, leave this section blank.
2. Subject Information a. Fill in the provider’s information.
3. Description of Suspected Misconduct a. The Category of Service list is found in the main documentation
panel in Case Tracker; this is not the same as the provider type. b. Date(s) of Conduct are the known dates the suspected fraud took
place; this may not be the same dates as the audit scope. c. Brief Summary of Allegation
i. Provide a short explanation of the allegations of fraud, in bullet form, starting with the most egregious, or in the order determined by management.
d. Medicaid statutes, rules, regulations and/or policies violated i. Check the boxes that apply to the allegations. ii. Provide the specific citation, if able.
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4. Amount paid to the provider in each of the past 3 years or during the period of alleged misconduct.
a. Email the Data Analytics Section (DAS) requesting the provider’s total billing broken down per year. Include the dates if the provider was only enrolled for a partial year.
5. All communications between the OIG and provider a. Letters – including the Records Request letter or the Audit
Announcement letter b. All email communication c. All phone conversations including the exit conference, if applicable d. All communications will be attached as Appendix A
6. Scope of the Audit
III. Creating the Body of the Referral A. Overview of Audited Provider Type
1. Provide specific information about the type of provider that was audited.
The template contains an example of specifics about personal care agencies.
B. Background 1. Fill in the provider name in the greyed in portion of the text. 2. Provide specific information about the provider audited and why the audit
was conducted.
The template contains an example of an audit completed based on a complaint.
C. Audit 1. Records Acquisition
a. Provide information about how the records were obtained, whether from an on-site visit or through a Records Request letter, and the date obtained.
2. Audit Details a. Provide the specific information for the greyed in and %xxx%
portions of the text body. 3. Recoupment Amounts
a. Provide the specific information for the greyed in and %xxx% portions of the text body.
4. Audit Stage a. Provide the stage of the audit at the time the referral is being created.
D. Exhibits
1. Provide a brief explanation of the allegation, information and documentation contained within each exhibit.
2. Include an exhibit for each of the bullet point allegations from the cover sheet.
3. The exhibit explanations are not to contain any personal health information (PHI); use initials when necessary.
4. Quantify what was found within the audit.
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E. Witness List
1. The auditor conducting the audit and/or creating the MFCEAU Referral will be listed.
2. Provide the contact information for any other person that assisted in the creation of the referral.
IV. Creating the Exhibit Packets
A. For each exhibit in the referral there will be an exhibit packet. B. Create a cover sheet by copying and pasting the paragraph in the Exhibits section of
the referral that pertains to the specific exhibit. C. Select examples from the documentation received for the audit that illustrates the
potential fraud. 1. The auditor will communicate with the supervisor if there are questions
about what documentation would be best and how many examples are needed.
D. Create any charts or graphs necessary to better show data trends. Work with DAS, if needed.
E. Scan the exhibit packets into pdf format to keep saved with the referral (MARS staff, see Step V.; PARS staff, see Step VI).
V. Routing the Referral - MARS
A. Create a subfolder in the L drive case folder and label it MFCEAU Referral. B. Create a subfolder in the MFCEAU Referral folder labeled Peer Review.
1. Place the MFCEAU referral and the exhibits into this folder. 2. Place a MARS Peer Review Referral Checklist (found in the main
Documentation panel in Case Tracker) into this folder. C. Complete a Referral Folder Route Form (found in the main documentation panel in
Case Tracker) and attach it to a BLUE folder. D. Route the blue folder with routing form on the front to the supervisor to assign out
for peer review. 1. Correct any issues the peer reviewer finds.
E. Once the peer review is complete route the folder back to the supervisor for review. 1. Correct any issues the supervisor finds.
F. Once the review from the supervisor is complete the folder will be passed to the section chief for review.
1. Upload the referral and all exhibits into Case Tracker for section chief review.
2. If any corrections are needed from the section chief, complete those and upload the corrected versions.
VI. Routing the Referral - PARS
A. Upload all required documents (MFCEAU referral, exhibits, and appendices) to Case Tracker.
B. Complete a Referral Folder Route Form (found in the main documentation panel in Case Tracker) and attach it to a BLUE folder.
C. Route the blue folder with routing form on the front to the supervisor for approval. 1. Correct any issues found by the supervisor.
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D. Once the review from the supervisor is complete the folder will be passed to the section chief for review.
1. If any corrections are needed from the section chief, complete those and upload the corrected versions.
VII. Credible Allegation of Fraud (CAF) Meeting
A. A meeting will occur with the Inspector General, Deputy Inspector General, legal counsel, section chief, supervisor and auditor to determine if the potential fraud is egregious enough to be considered a credible allegation.
B. The auditor will present the referral and exhibits during the meeting. C. The Inspector General, Deputy Inspector General and legal counsel will determine if
the referral will be sent to MFCEAU as a credible allegation, provider notice, or not at all. Note: Another outcome of a CAF meeting may be a referral to the Unified Program Integrity Contractor. Refer to the “Unified Program Integrity Contractor” instructions.
VIII. Creating a Letter A. Provider Notice Letter
1. Access the Letters panel in the specific case in Case Tracker. 2. Select the Provider Notice Letter and fill in any information needed. 3. Save letter in Case Tracker. 4. Route the empty blue folder to the supervisor for approval and final routing.
B. Credible Allegation of Fraud Letter 1. Email administrative staff and request they open the payment action panel in
Case Tracker (the auditor will provide the case number). 2. Access the Letters panel in the specific case in Case Tracker. 3. Select the Credible Allegation MFCEAU Referral Response letter and fill in
any information needed. 4. Select the Credible Allegation Notice to Provider letter and fill in any
information needed. 5. Save letter in Case Tracker. 6. Route the empty blue folder to the supervisor for approval and final routing.
If MFCEAU decides to open the case, they may contact the auditor for more information. The auditor should thoroughly document their research/findings while they’re doing their audit. MFCEAU may contact the auditor as needed throughout their investigation and may notify the auditor of their final determination.
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Submitting Additional Exhibits If the auditor has additional information or exhibits to submit to MFCEAU:
1. Prepare the exhibits. Label each as “Supplemental Exhibit [#]” and include a brief description of what the exhibit includes.
2. Draft a Fraud Follow-up Letter.
3. Route the exhibits and the letter to the appropriate supervisor.
Implementation of Medicaid Payment Suspensions
Note: Payment suspension information is entered into SURS by OIG Admin staff, not by auditors. Information about payment suspensions is being included here as reference material in case an auditor needs to look up information in SURS and iC2 about a payment suspension. Steps for payments distributed by the Department’s fiscal agent:
1. OIG enters the following information into the Payment Action and Payment Suspension
panels in SURS (Note: nothing is entered in the “Current$” field):
2. SURS sends the information to iC2, where it is visible in the Payment Hold Maintenance
panel.
A. In iC2, select Main Menu. B. Select Financial.
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C. Select Payment Holds. D. From the Open Tab folder, select Payment Hold Maintenance. E. Sort by Hold Reason. Payment suspensions from SURS will have a Hold Reason of
“Credible Allegation of Fraud”.
3. The payment suspension is also reflected on the provider’s information screen in iC2:
4. iC2 prevents the disbursement of funds effective the Sunday of the week the suspension begins. Example: If MFCEAU accepts the Credible Allegation of Fraud on a Friday afternoon, the Payment Suspension will be entered into SURS on Friday, the payment suspension will start the following Sunday, and the letter will be mailed to the provider on the following Monday.
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5. The “Current$” field in the SURS Payment Suspension updates to show how much money
has been held from the provider to date.
Steps for payments distributed by other entities:
1. Fiscal agent receives the Medicaid Payment Suspension Letter from the OIG.
2. Fiscal agent enters the effective date on the letter in their internal control system to ensure
Medicaid payments are not issued to the suspended entity:
3. Fiscal agent does not distribute any Medicaid funds to the suspended entity, including
pending or scheduled payments, after the date identified in the letter. The date of suspension is not related to any dates of service – therefore, a payment from dates of service prior to the suspension that were processed and scheduled for payment for a date after the effective date of the suspension will not be paid.
4. Fiscal agent places any invoices or timesheets received on “hold” and issues payment if the
suspension is discontinued.
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Unified Program Integrity Contractor (UPIC)
UPICs perform fraud, waste, and abuse detection, deterrence and prevention activities for Medicare and Medicaid claims processed in the United States. Specifically, the UPIC’s perform integrity related activities associated with Medicare Parts A, B, Durable Medical Equipment (DME), Home Health and Hospice (HH+H), Medicaid, and the Medicare-Medicaid data match program (Medi-Medi). The UPIC contracts operate in five (5) separate geographical jurisdictions in the United States and combine and integrate functions previously performed by the Zone Program Integrity Contractor (ZPIC), Program Safeguard Contractor (PSC) and Medicaid Integrity Contractor (MIC) contracts.
Source: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Contractor-Directory-Interactive-Map/
1. Complete a State Collaboration Vetting Form. a. Do not fill out the following:
Date Sent to State:
Sent to:
Sent by: These are completed for referrals sent to the state from the UPIC.
b. In the Provider Information section: i. Fill in all the fields except:
Provider TPI – this can be deleted
ZPIC Internal Tracking Number - leave this blank; this will be filled in by the UPIC.
Previous Reviews/Administrative actions taken (UPIC and/or MAC) – leave this blank for UPIC to complete, unless OIG is aware of previous reviews.
ii. For “HHS_OIG Exclusion List”, access the exclusion list at https://exclusions.oig.hhs.gov and search for the provider. If the provider is listed, indicate this on the State Collaboration Vetting Form.
c. Fill in the State to Complete section.
“Non-OIG State administrative actions” refers to Department of Safety and Professional Services (DSPS) license suspensions, Department of Quality Assurance (DQA) corrective plans, etc., that the auditor is aware of.
o For DSPS suspensions, auditors may refer to http://dsps.wi.gov.
“Current or past known State OIG reviews/actions” refers to previous OIG audits, suspension of payments, etc.
d. Fill in the Potential Medicaid Allegations section.
This information will be similar to the information included on a fraud referral (refer to the “Medicaid Fraud Control and Elder Abuse Unit (MFCEAU)” instructions).
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e. Leave the Response from the State section blank. This is only completed for referrals sent to the state from the UPIC.
f. In the Contract Information section: i. Fill in the “State Investigations Contact (Name & Phone)” and “State Audit
Contract (Name & Phone)” sections with the auditor’s name and phone number.
ii. Leave the other sections blank.
2. Upload the completed form into the Documentation panel in the SURS case.
3. Complete an Audit Folder Route Form.
4. Attach the Audit Folder Route Form to a blue folder and route to an audit supervisor for review and approval.
5. The appropriate Section Chief will review the referral. If approved, the section chief will send the referral to the UPIC.
When requested, the Data Analytics Section will provide data extracts and send them to the UPIC. The UPIC will complete an Investigation Plan and submit to CMS for approval. Once the UPIC has received a response from CMS, they will notify the state and begin their investigation.
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Appendix A: Acronyms
ACA Affordable Care Act (Federal Regulations)
ALJ Administrative Law Judge
A/R Accounts Receivable
CAF Credible Allegation of Fraud
CCC Child Care Coordination
CCS Comprehensive Community Services
CMS Centers for Medicare and Medicaid Services
CPT Code Current Procedural Terminology Codes
CT Cash Transaction
DHA Division of Hearings and Appeals
DHCAA Division of Health Care Access and Accountability
DHS Department of Health Services
DME Durable Medical Equipment
DMS Disposable Medical Supplies
DMS Division of Medicaid Services
DOS Dates of Service
DRG Diagnosis Related Group
DQA Department of Quality Assurance
DSPS Department of Safety and Professional Services
DX Diagnosis
EHR Electronic Health Records (Federal Regulations)
EOB Explanation of Benefits
FIRE Fraud Investigation, Recovery and Enforcement Section (Recipient Fraud)
FFS Fee for service
FQHC Federally Qualified Health Centers
FT Financial Transaction
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HCE Health Care Efficiencies
HCPCS Healthcare Common Procedure Coding System
HMO Health Maintenance Organization
ICD-9-CM International Classification of Diseases, 9th edition, Clinical Modification
ICD-10-CM International Classification of Diseases, 10th edition, Clinical Modification
ICN Internal Control Number
MA Medicaid
MAR Medical Audit Review
MFCEAU Medicaid Fraud Control & Elder Abuse Unit
MII Medicaid Integrity Institute
NAC National Advocacy Center –Training center in South Carolina
NDC National Drug Codes
NPI National Provider Identifier
OI Other Insurance
OIG Office of the Inspector General
OLC Office of Legal Council
PAR Program Audit and Review
PD Position Description
PEP Performance Expectations and Planning
PNCC Prenatal Care Coordination
QAR Quality Assurance and Review
RAC Recovery Contract Auditor (Federal)
RHC Rural Health Centers
RX Prescription
SMV Specialized Medical Vehicle
SURS Surveillance Utilization and Review
TPL Third Party Liability
UPIC Unified Program Integrity Contractor
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Appendix B: Narrative Findings Example
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Appendix C: Provider Payment at Prelim/Amended Prelim
Scenarios
Scenario 1:
Provider calls the auditor because they:
1. Have received a Preliminary Findings letter or Amended Preliminary Findings letter,
AND
2. Agree with all audit findings, AND
3. Want to submit a check for the total overpayment amount.
Auditor response:
1. Thank the provider for contacting OIG/the auditor.
2. Inform the provider that the payment can be mailed within 30 days of when they received
the letter to:
Wisconsin BadgerCare Plus
ATTN: Cash Unit
313 Blettner Blvd
Madison, WI 53784
3. Instruct the provider to include a copy of the Preliminary Findings letter or Amended
Preliminary Findings letter with the payment.
4. Thank the provider again for contacting OIG/the auditor.
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Scenario 2:
Provider calls the auditor because they:
1. Have received a Preliminary Findings letter or Amended Preliminary Findings letter,
AND
2. Agree with all audit findings, AND
3. Want to have the total overpayment amount withheld from future remittances.
Auditor response:
1. Thank the provider for contacting OIG/the auditor.
2. Instruct the provider to send a written correspondence (mail, email, or fax) stating they
are in agreement with the findings and wish to have total overpayment amount (as listed
on the audit report) withheld from future remittances. The correspondence must be sent
within 30 days of when the provider received the Preliminary Findings letter or Amended
Preliminary Findings letter.
3. Thank the provider again for contacting OIG/the auditor.
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Scenario 3:
Provider calls because they:
1. Have received a Preliminary Findings letter or Amended Preliminary Findings letter,
AND
2. Agree with SOME audit findings, AND
3. Want to submit a check for the findings for which they agree, AND
4. Want to submit rebuttal for the findings for which they do not agree.
Auditor response:
1. Thank the provider for contacting OIG/the auditor.
2. Inform the provider that the payment can be mailed within 30 days of when they received
the letter to:
Wisconsin BadgerCare Plus
ATTN: Cash Unit
313 Blettner Blvd
Madison, WI 53784
3. Instruct the provider to include a copy of the Preliminary Findings letter or Amended
Preliminary Findings letter with the payment.
4. Inform the provider that they can mail rebuttal documentation to the address at the top of
the letter. Rebuttal documentation must be sent to OIG within 30 days of when the
provider received the Preliminary Findings letter or Amended Preliminary Findings
letter.
5. Instruct the provider to include a copy of the audit report that indicates which findings
they agree with (and submitted payment for) and which findings they disagree with.
6. Thank the provider again for contacting OIG/the auditor.
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Scenario 4:
Provider calls the auditor because they:
1. Have received a Preliminary Findings letter or Amended Preliminary Findings letter,
AND
2. Agree with all audit findings, AND
3. Want to set up a payment plan.
Auditor response:
1. Thank the provider for contacting OIG/the auditor.
2. Instruct the provider to submit their proposed payment plan to OIG in writing (mail,
email, or fax). The correspondence must be sent within 30 days of when the provider
received the Preliminary Findings letter or Amended Preliminary Findings letter.
3. Instruct the provider to indicate if they would plan on submitting payments via check or
if they want payments withheld from future Medicaid remittances.
4. Thank the provider again for contacting OIG/the auditor.
(Note: The payment plan review process is described in the Financial Transaction Guide located
at L: > Oig Ma > Auditor > Audit Procedures)
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Scenario 5:
Provider emails the auditor because they:
1. Have received a Preliminary Findings letter or Amended Preliminary Findings letter,
AND
2. Agree with all audit findings, AND
3. Want to submit a check for the total overpayment amount.
Auditor response:
1. Send an email response with language similar to the following:
Dear [Provider Name],
Thank you for contacting me regarding the return of your overpayment. Please submit a check
for the total overpayment amount listed on the last page of the audit report to the following
address:
Wisconsin BadgerCare Plus
ATTN: Cash Unit
313 Blettner Blvd
Madison, WI 53784
Payment must be sent within 30 days of when you received the [Preliminary Findings or
Amended Preliminary Findings] letter. Please include a copy of the letter with your payment. If
you have any additional questions, please contact me.
Thank you.
[Auditor Name]
(Note: the above language can be modified as needed to address the other provider payment
scenarios presented earlier in this document.)
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Scenario 6:
Provider receives a Preliminary Findings letter or Amended Preliminary Findings letter and
submits a written response to OIG indicating they agree with the audit findings, but does not
indicate how they will return the overpayment to the Department.
Auditor response:
1. Call the provider.
2. Thank the provider for responding to the Preliminary Findings letter or Amended
Preliminary Findings letter.
3. Inform the provider that if they agree with the audit findings, they have the option of
returning the overpayment amount listed on the audit report.
a. If the provider indicates they have already returned the overpayment via check or
by adjusting claims:
i. Ask the provider for details about the payment (i.e. when was the check
mailed, where was it mailed) or the claim adjustments (i.e. when were the
adjustments submitted).
ii. Thank the provider again for responding to the Preliminary Findings letter
or Amended Preliminary Findings letter.
iii. Follow the current process of verifying if a payment was received or if
adjustments were made (L: > Oig Ma > Auditor > Audit Procedures >
Financial Transactions > Financial Transaction Guide).
4. Inform the provider that overpayments can be returned one of two ways:
a. The provider can submit a check to the following address:
Wisconsin BadgerCare Plus
ATTN: Cash Unit
313 Blettner Blvd
Madison, WI 53784
If the provider chooses this method, instruct the provider to include a copy of the
Preliminary Findings letter or Amended Preliminary Findings letter with the
payment.
b. The provider can have the overpayment amount withheld from future remittances.
If the provider chooses this method, instruct the provider to send a written
correspondence (mail, email, or fax) stating they are in agreement with the
findings and wish to have total overpayment amount (as listed on the audit report)
withheld from future remittances.
5. Thank the provider again for responding to the Preliminary Findings letter or Amended
Preliminary Findings letter.