#ozprevention

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.

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.

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. 

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:

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.  

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.