Corrective Action for Medicaid/NCHC QC Errors and Deficiencies

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Corrective Action for Medicaid/NCHC QC Errors and
Deficiencies
Prepared and Presented by Shara Britt, Assistant
Chief DMA Quality Assurance and Special Projects
Section
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DMA Quality Assurance Reviews

• Medicaid Eligibility Quality Control (MEQC)
• Monthly MEQC reviews- specific populations or
  certain geographic areas will begin again with FY
  2016
• Focused reviews planned by state/approved by CMS
  or directed by CMS (currently being done for
  FY2014 FY2016)
• Payment Error Rate Measurement (PERM)
• FY2013 - most recent PERM cycle completed for NC
• FY2014-FY2016- PERM eligibility reviews postponed
  by CMS until FY2017 for all states

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FY2014-FY2016 - Focused Medicaid/NCHC Reviews

• CMS has given states specific sampling and review
  requirements

• Four rounds of reviews(six-month sampling
  periods)
• First two rounds focused on MAGI
• Third round will focus on MAGI and non-MAGI
• Fourth round - CMS still has to provide
  requirements and type of universe

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PERM FY2013 Medicaid Error Rates

• Medicaid actives- 972 cases reviewed, 31 error
  cases, 40 cases with deficiencies(4.56 payment
  error rate 1.34 active case error rate)
• Medicaid negatives 384 cases reviewed, 91 error
  cases, 40 cases with deficiencies (23.74
  negative case error rate)
• Note Deficiencies/technical errors were required
  to be reported to CMS but did not factor into
  error rates

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PERM FY2013 NCHC Error Rates

• NCHC actives- 504 cases reviewed, 32 error cases,
  11 cases with deficiencies(3.21 payment error
  rate 6.34 active case error rate)
• NCHC negatives 204 cases reviewed, 91 error
  cases, 40 cases with deficiencies (20.12
  negative case error rate)
• Note Deficiencies/technical errors were required
  to be reported to CMS but did not factor into
  error rates

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Round 1 FY2014-2016 Error Rates

• Medicaid actives- 44 cases reviewed, 2 error
  cases (4.5 active case error rate)
• Medicaid negatives 126 cases reviewed, 55 error
  cases (44 active case error rate)
• NCHC actives 5 cases reviewed, 0 error
  cases(0)
• NCHC negatives- 0 cases reviewed
• Note Deficiencies/technical errors were not
  required to be reported to CMS. No payment error
  rate calculated.

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Round 2 FY2014-2016 Error/Deficiency Rates

• Medicaid actives- 75 cases reviewed, 4 error
  cases, 26 cases with deficiencies (40 cases with
  errors or deficiencies)
• Medicaid negatives 25 cases reviewed, 0 error
  cases, 15 cases with deficiencies (60 cases with
  errors or deficiencies)
• NCHC actives 75 cases reviewed, 9 error cases,
  23 cases with deficiencies (43 cases with errors
  or deficiencies)
• NCHC negatives- 25 cases reviewed, 0 error cases,
  15 cases with deficiencies (60 cases with errors
  or deficiencies)

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Review Requirements

• Eligibility verification and processing
• Income and resource calculations
• Appropriate and accurate notices
• Timeliness of processing(actives and negatives)
• Sanctions
• Transfers to FFM for negative actions

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Reasons for Errors/Deficiencies

• Incorrect program or program classification
• Citizenship/identity not verified
• OVS not completed and reviewed
• OVS not used for verification of income
• Income of budget unit member not used
• Income calculation errors
• Residency not verified
• Insurance information not entered into NCFAST

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Reasons for Errors/Deficiencies

• No denial or termination notice sent
• Timely notice does not show 10th work day or
  shows incorrect date for the 10th work day
• Terminated prior to 10 work days
• Incorrect reasons on denial or termination
  notices
• Timeliness of actions
• Resources not verified or excess resources

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Notification of Errors/Deficiencies

• Notification of errors or deficiencies (technical
  errors) is sent by DMA Quality Assurance(QA) via
  DMA-7002, Active Case Error/Technical Error
  Report or DMA-7004, Negative Case Error/Technical
  Error Report
• DMA-7001, County Department Report of Errors and
  Corrective Action is sent at time DMA-7002 or
  DMA-7004 is sent

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Corrective Action Activities Required

• County should take corrective action to correct
  the case
• Train staff to prevent similar errors from
  happening
• Implement monitoring activity to ensure staff are
  appropriately implementing the training they
  received
• Provide followup training, if necessary
• Refer client responsible errors to county Program
  Integrity staff
• Keep records of training
• Report to DMA Quality Assurance via DMA-7003,
  Corrective Action Report
• corrective action taken on the case and
  information regarding training and referral to
  Program Integrity

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Questions

• Contact Information
• Shara.Britt_at_dhhs.nc.gov
• 919-814-0192