4171017 Proposed Rules Governing Medicaid Recovery Audit Contractor Program

DEPARTMENT OF HEALTH CARE FINANCE

 

NOTICE OF PROPOSED RULEMAKING

 

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in An Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 744; D.C. Official Code §1-307.02 (2006 Repl.;  2012 Supp.)), and Section 6(6) of  the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code §7-771.05(6)(2008 Repl.)), hereby gives notice of the intent to adopt  a new Chapter 93 (Medicaid Guidelines for Recovery Audit Contractors) of Title 29 (Public Welfare) of the District of Columbia Municipal Regulations (DCMR). 

 

Section 6411 of the Patient Protection and Affordable Care Act of 2011 (the Affordable Care Act or ACA), approved March 23, 2010 (Pub. L. No. 111-148; 124 Stat. 119), requires State Medicaid programs to enter into contracts with one or more Recovery Audit Contractors (RACs).  The RAC agreement authorizes the review of Medicaid claims to identify and reconcile Medicaid provider overpayments and underpayments.

 

In September 2011, the Department of Health and Human Services (HHS), Centers for Medicare and Medicaid Services (CMS), issued a final rule governing RACs for eventual publication in the Code of Federal Regulations.  That rule directs States to provide prospective contractors and providers with additional guidance about the Medicaid RAC program, with the ultimate goal of providing improved program integrity for the benefit of the District, its residents, and providers.

 

To achieve compliance, DHCF is amending the District of Columbia State Plan for Medical Assistance (State Plan) to reflect these changes. The State Plan amendment was approved by the Council of the District of Columbia (Council) on June 4, 2012 through PR19-0694 and awaiting approval by CMS.    

 

The Director gives notice of the intent to take final rulemaking action to adopt these proposed rules in not less than thirty (30) days from the date of publication of this notice in the D.C. Register.     

 

Chapter 93, Medicaid Guidelines for Recovery Audit Contractors, of Title 29 DCMR is added to read as follows:

 

93                    MEDICAID RECOVERY AUDIT CONTRACTOR PROGRAM

 

9300                GENERAL PROVISIONS

 

9300.1                                      In accordance with the requirements set forth in Section 1902(a)(42)(B)(i) of the Social Security Act (the Act), (42 U.S.C. § 1396a(a)(42)(B)(i)) and  42 C.F.R. §§ 455.500 et seq.,  the Department of Health Care Finance (DHCF) shall establish the Medicaid Recovery Audit Contractor (Medicaid RAC) Program. 

9300.2                          The Medicaid RAC Program shall support program integrity efforts by identifying overpayments and underpayments, and fraudulent and abusive claims activity. 

9300.3                          Subject to the requirements set forth in Title 27 DCMR, DHCF shall contract with one (1) entity that shall be the Medicaid RAC pursuant to 42 CFR §§ 455.500-455.518.

9300.4                          The following claims and payments may be excluded from review and audit under the Medicaid RAC Program:

(a)                Claims associated with managed care, waiver, and demonstration programs;

(b)               Payments made for Indirect Medical Education (IME) and Graduate Medical Education (GME);

(c)                Claims older than three (3) years from the date of reimbursement;

(d)               Claims that require reconciliation due to beneficiary liability; and

(e)                Unpaid claims.

9300.5                          In accordance with 42 C.F.R. §§ 455.506(c) and 455.508(g), DHCF shall ensure that no claim audited under the Medicaid RAC Program has been or is currently being audited by another entity.

 

9301                   MEDICAL RECORDS REQUESTS

 

9301.1             Each provider shall make medical records available to the Medicaid RAC upon request, subject to the provisions in this section.  Providers may submit medical records in hardcopy or electronic format.

9301.2                          Providers shall have five (5) business days from the date of the Medicaid RAC request to provide the requested medical records.  Failure to submit the requested records within this timeframe will result in the Medicaid RAC making a determination of improper payment.

 

9302                GUIDELINES FOR RECOUPING OVERPAYMENTS AND RECONCILING UNDERPAYMENTS

 

9302.1                          A Medicaid provider may be subject to claim recoupment or reconciliation based on the Medicaid RAC findings. 

9302.2             A determination of overpayment or underpayment shall be based on, but not limited to, one or more of the following:

                                                 (a)            Whether the service underlying the claim is covered;

                                                (b)            Whether the claim resulting from the service was priced correctly;

                                                 (c)            Whether the provider properly coded the claim;

                                                (d)            Whether the claim duplicates a previously paid claim; and/or

                                                 (e)            Whether the Medicaid Management Information System (MMIS) failed to apply relevant payment policies.

9302.3             DHCF shall notify a provider, in accordance with the requirements set forth in Chapter 13 of Title 29 DCMR, when a claim is subject to recoupment or reconciliation based on the Medicaid RAC’s determination.

9302.4             Pursuant to § 1307 of Title 29 DCMR, a provider may appeal an overpayment determination by the Medicaid RAC to the Office of Administrative Hearings (OAH) within fifteen (15) calendar days of the date the notice was sent.

                       

9399                DEFINITIONS

For the purposes of this chapter, the following terms shall have the meanings ascribed:

 

Audit – a systematic process where an entity reviews Medicaid claims, obtains evidence, evaluates findings, and determines compliance with applicable laws, regulations, and policies.

Beneficiary – an individual who is eligible for Medical Assistance (Medicaid) under Titles XIX or XXI of the Social Security Act.

Demonstration – a project approved by CMS and authorized under section 1115 of the Social Security Act.

                        Managed Care – the program authorized under section 1915(b) of the Social Security Act in which Medicaid beneficiaries are enrolled into managed care organizations to receive services.

                        Waiver – a program operated by a state or by the District of Columbia pursuant to a CMS-approved application to waive standard Medicaid provisions to deliver long term care in community-based settings.

Comments on these proposed rules shall be submitted in writing to Linda Elam, Ph.D., M.P.H.,

Deputy Director - Medicaid, Department of Health Care Finance, 899 North Capitol Street, NE,

6th Floor, Washington, DC 20002, via email at [e-mail], online at www.dcregs.dc.gov, or at [phone], within thirty (30) days after the date of publication of this notice in the D. C. Register. Additional copies of these proposed rules may be obtained from the above address.