Nearly 500 Medicaid audits are under way in 17 states, and the program will roll out to the entire country through the end of the year, according to CMS representatives who spoke on the Medicaid Integrity Program Special Open Door Forum on Wednesday.
CMS hopes to identify additional contractors by the end of the week. These contractors, known as Medicaid Integrity Contractors, are firms CMS has chosen to carry out the following Medicaid Integrity Program goals:
- Review provider actions to determine whether fraud, waste, or abuse may have occurred
- Audit provider claims
- Identify overpayments
- Educate those involved in Medicaid administration, providers, managed care entities, beneficiaries, and others with respect to payment integrity and quality of care
There are three types of contractors: Review, audit, and education MICs. The review MICs analyze data and identify issues to pass on to audit MICs to pursue, according to CMS. Education MICs will provide education to providers and others on Medicaid payment integrity and quality of care.
CMS acknowledged on the call that it could do a better job of provider outreach, and it is taking measures to increase educational efforts, now that it has finished building the Medicaid Integrity Program organization and developing the audit process.
Fortunately, additional resources will soon become available for providers. CMS plans to soon release FAQs, a procurement timeline, background on the program, and its goals, as well as other information on the Medicaid Integrity Program Web site. CMS also plans to release Web-based training currently in development for pharmacies.
Hospitals aren't the only providers that need to prepare: 44% of the current audits focus on hospitals, but 29% are on long-term care facilities, 21% of audits are on pharmacies, and the remaining 6% are on physicians, labs, transportation, and other types of providers, according to CMS.
RACs vs. MICs
MICs have been termed "RACs for Medicaid," but there are certainly differences between the programs. For example, the RAC lookback period is three years, but MICs base the length of time on individual state lookback guidelines. Similarly, the number of days a provider has to produce medical record copies for MICs is dependant on state rules, unlike with RACs, where providers have 45 days regardless of their location.
In addition, MICs have no set medical request limits, while RACs max out at 200. Also, CMS will not reimburse providers for the cost of copying records, which is also different from the RAC program.
And unlike RACs, MICs are not paid by contingency fee, but rather through a sort of fee-for-service model. The dollars MICs recover aren't tied to their compensation, according to CMS, although they will be eligible for bonuses based on how "effective and efficient" they are. Finally, in some cases MICs will do desk audits, and in other instances, auditors will come on-site to do the reviews.
MICs will also attempt to coordinate with RACs so as not to audit the same facilities simultaneously, CMS Medicaid Integrity Program field director Robb Miller said on the call.
Editor's note: If you've undergone a MIC audit, we want to hear from you.
CMS will post an audio recording and transcript to the Special Open Door Forum Web site for 30 days beginning July 24.
To contact CMS regarding the Medicaid Integrity Program or audits, e-mail CMS.