#ozprevention

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An Ounce of Prevention

This week’s topic concerns a responsibility that DIDD employees share with the provider community.  Policy 70.2.1, “Reporting Fraud, Waste, and Abuse of Government Funds and Property”, specifies in Section VI.A.(4) that DIDD shall….“Routinely include information on how to report fraud, waste or abuse of government funds and property in DIDD newsletters.”

Policy 70.2.1 specifies the protections employees have as “whistleblowers” and the duties employers have to respond to allegations of Fraud, Waste, and Abuse.  A copy of the policy can be found at this link.

This policy also references signs which shall be prominently displayed, “which inform staff, volunteers, and contractors how to report wasteful, inefficient, or fraudulent activity involving government funds and property”. For your convenience the poster used in DIDD offices and facilities can be found on the DIDD website at this link.

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An Ounce of Prevention

Recently, DIDD underwent an audit related to the department’s compliance with the Deficit Reduction Act of 2005 (DRA).  Section 6032 of the DRA requires all covered entities, i.e., those contractors that receive or make annual Medicaid payments of $5 million or more, to educate employees, contractors or agents about certain fraud and abuse laws, including the reporting of false claims and whistleblower protections.  

As a reminder, agencies that fall within this financial threshold are required to complete the Deficit Reduction Act questionnaire which is provided and reviewed as part of the Fiscal Accountability Review (FAR) each year. It is important for agencies to have an appropriate management staff member sign the questionnaire on the last page. This attests that the agency has educated its employees about these important issues.  There are two lines for this signature.  The management staff member should print his/her name and title on the first line and then sign on the signature line.

Additionally, the DRA requires that if the covered entity has an employee handbook, the handbook include a specific discussion of the fraud and abuse laws, the right of employees to be protected as whistleblowers and the entity’s compliance policies.  To clarify, a provider is not required to have an employee handbook for the purpose of DRA compliance.  However, if the provider has an employee handbook, it must include information about reporting false claims and whistleblower protections, even if the information is provided to employees elsewhere.

Thank you for your attention to these details concerning the DRA.  Should you have questions, or if you would like a copy of the questionnaire for reference, please contact Laura Key, FAR Director, at [email protected].

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An Ounce of Prevention

This week’s topic is Family Model Residential Services (FMRS).  Providers are reminded that additional staff are required for Levels 4 and 5 of FMRS. For Level 4, there must be documentation of up to 10 hours per week of additional staff assistance.  For Level 5, there must be documentation of no less than 11 hours per week of additional staff.  Recently, Quality Assurance and FAR reviewers have noticed at least two situations where these minimums have not been met in a given week.  Because these issues can no longer be addressed by a rate adjustment, failure to provide and document the presence of the additional staff can result in recoupment of the entire week of FMRS billed. For full details on the requirements associated with FRMRS Levels, please follow this link on the DIDD website.

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An Ounce of Prevention

This week’s focus is on personal funds management.  DIDD policy 80.4.3 applies to providers who serve as an individual’s Representative Payee.  We would like to take this opportunity to emphasize the two following requirements in an effort to help providers from becoming obligated to repay personal funds to people they support in this capacity. 

Making a check from a person supported’ s account payable to a staff member is never acceptable (see section VI.C.2.b which specifies that one of the prohibited practices includes “Using a person’s personal funds for staff benefit.”)

Receipts that are simply missing are a common issue when personal funds are surveyed or audited.  A related issue comes into play when receipts are stored “loose” and sorted at a later date, sometimes at the end of the week or even the month.  This approach often results in receipts that cannot be traced back to a specific purchase and people needing to be repaid. 

Having staff take time on a daily basis to ensure that checks are properly written and receipts are properly accounted for, benefits individuals as well as providers.  For additional details and clarification, this policy is available on the DIDD website at this link.

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An Ounce of Prevention

This week’s topic is the Day Service limit of 243 claims per calendar year. We would like to take this opportunity to remind providers that edits have been implemented within PCP to enforce this limit.  If your billing staff attempt to bill more than the allowed annual maximum, they will receive an error message and the entry will not be saved. As noted in early 2015, the intent of this edit is to promote accuracy in billing; reduce opportunities for fraud, waste, and abuse; and strengthen our compliance with CMS and TennCare requirements.

On a related issue, we recognize that when a person has more than one Day Service provider or transitions to a new provider, it is difficult to be aware of the total number of units of service provided. In order to alleviate this issue, Billing Coordinators for each Region now have access to a report with year-to-date Day Service units billed per person supported. We encourage providers that share Day Services, or who have just begun supporting a person, to contact their respective Billing Coordinator when there are questions about the number of units of Day Service a person has received.

For your reference, contact information for the Regional Billing Coordinators is:

West          Vickie Connell         [email protected]       901-745-7760 Middle      Melissa Hafeli         [email protected]      615-231-521 East           Randy Carrigan       [email protected]    865-594-9295  

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An Ounce of Prevention - Timely Billing

This week’s topic is timely billing, which was previously addressed on June 6, 2014.  With the implementation of the Statewide Waiver cap, the significance of submitting claims that are timely and accurate is raised to an even higher level.  When claims are entered into Provider Claims Processing (PCP) for payment; the provider is attesting that the services being billed have been provided as authorized and that required supporting documentation is in place.  Late and inaccurate billing, as well as adjustments and voids, will impact the amount of funds available within the waiver cap.

Timely billing is addressed in the Provider Agreement, Clause A.19:

Per the clause A.19. Service Authorization (a) (ii): DIDD will refuse payment to the Provider for services billed to DIDD that are beyond the level of services authorized by DIDD through Individual Support Plans or Individual Support Plan Amendments, exceed payment rates for these services or are not billed to DIDD within the appropriate time frame after the delivery of services.

A.19. Service Authorization (d): All payments to the Provider for authorized services are final payments for the billing period invoiced by the Provider and paid by DIDD or submitted to TennCare for payment by DIDD.  The Provider shall provide written notification to DIDD setting forth the amount, details, and basis of any payment dispute within thirty (30) days after receiving payment for services.

All providers have an initial six (6) weeks to submit their billing into PCP as “Current”. Providers also have an additional 6-7 weeks to submit any previously unbilled claims into PCP as “Late Bills” and the same 6-7 weeks to correct any errors that might have been made to any previously submitted claims as “Adjustments.” Claims submitted and/or adjusted within this 12-13 week period are considered timely.  The exact dates that claims can be submitted and adjusted varies from month to month due to the timing of sweep dates for processing and payment.  The current dates available for submission of initial claims and adjustment of previously submitted claims are always displayed on the PCP login screen.  

We want to take this opportunity to remind providers that billing for services which have not been provided and failure to maintain adequate documentation are two of the reasons for recoupment that are specifically cited in the Provider Agreement.  This type of billing issues may be considered fraud by TennCare and can result in fines and other penalties, as well as recoupment.

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Special Edition: An Ounce of Prevention

The Statewide Waiver cap makes the utilization of various reports more important than ever. These reports are sent to the designated agency email address. As a courtesy, DIDD formats the information from the TennCare Remittance Advice, which is the official record, into an Excel spreadsheet, referred to as the Adjudicated Claims Report (ACR), so that providers may manipulate the payment information into their accounting records. The ACR, along with the Cost Plan Reports and Void Reports, will be more vital than ever in updating your records of those served.

To meet HIPAA requirements, all reports are sent using secure email, and are either stored on a secure site for retrieval within 14 days by the provider, or received by the certified secure address in entirety. It is the providers’ responsibility to copy, distribute and retain all reports for future reference. Reports sent to the secure site must be retrieved and downloaded by the provider within 14 days of the notice being sent. The fee for resending a report is $20.00 per report.

Due to a limit of one designated email address per provider, it is extremely important that the email address not be specific to an individual and is accessible only by those that need the information.

It is critical that a notice is sent to [email protected] for a designated secure email address change as soon as possible. Once the old address becomes inactive or unserviceable valuable information will not be available to the provider. In order to initiate a change the request must be made on provider letterhead, contain the provider 5 digit id# and be signed by the Executive Director.

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Ounce of Prevention

This week we focus on billing requirements for Day Services.  Per the waiver definition, Day Services are limited to 5 claims per calendar week and 243 claims per calendar year.  Please note that effective April 1, 2015, edits will be implemented within PCP to enforce these limits.  This is being done to promote accuracy in billing, reduce opportunities for fraud, waste, and abuse, and strengthen our compliance with CMS and TennCare requirements. These edits will also provide timely feedback to the provider when Day Service limits are exceeded to allow for follow up review and evaluation.