1. Claims for federal financial participation in the costs of waiver services are based on state payments for waiver services that have been rendered to waiver participants, authorized in the service plan, and properly billed by qualified waiver providers in accordance with the approved waiver.
The claims for federal financial participation for these waiver services are subject to the same policies and procedures that the DOH - Office of Health Insurance Programs (OHIP) through the eMedNY system uses to claim federal financial participation for all other Medicaid services.
Each waiver provider is assigned a separate waiver provider identification number in eMedNY to assure only qualified waiver providers are billing for services. Each waiver service is assigned a unique rate code.
Upon approval of the waiver participant's ISP, a waiver participant Exception Code 60, which is unique to the NHTD waiver, is assigned by the LDSS to assure that claims are paid only for individuals enrolled in the waiver on the date of service.
All Medicaid claims submitted to eMedNY are subject to a series of edits to ensure validation of data. These edits include: whether the waiver participant is Medicaid eligible; whether the individual was enrolled in the waiver on the date of service; and whether the Service Providers are enrolled waiver providers.
The QMS and DOH WMS performs a random retrospective review of at least five-percent (5%) of SPs in Year One of the waiver; two-percent (2%) in Year Two; and one-percent (1%) in Year Three. DOH WMS compares the SPs reviewed with the claims for each waiver participant in this review to verify the waiver services provided are authorized in the SP. DOH WMS runs queries to review participant SPs against claims data from the eMedNY system. Discrepancies may be referred to the OMIG.
The responsibilities of the OMIG include, among other responsibilities, the Medicaid audit function. At least five-percent (5%) of NHTD waiver providers will be audited annually by the OMIG. The DOH WMS, QMS, and/or the RRDS may also recommend waiver providers to be audited.
Upon completion of each audit, final audit reports will be written disclosing deficiencies pertaining to claiming, record keeping and provision of service. These final audit reports will be sent to the waiver provider with a copy provided to DOH WMS.
The QMS conducts Participant Satisfaction Surveys to ask waiver participants about their experiences with the services they have received and whether they have received the services authorized in their SP. Responses will be shared with the RRDS and DOH WMS who may request a financial audit of the waiver providers if there are areas of concern.
Based on DOH surveys, a financial audit may be triggered if areas of concern are identified.
To ensure providers of Environmental Modifications (E-mods), Assistive Technology (AT), Community Transitional Services (CTS) and Moving Assistance are billing properly, they are required to submit projected cost estimates and actual costs to the SC. Upon financial audit of these providers, DOH WMS will ensure the claim amount is the same as the amount that was approved.
As with any Medicaid service, the costs of waiver services that are the responsibility of a third party must be paid by that third party. If a waiver participant has third-party insurance coverage, he/she is required to inform the LDSS of that coverage.
Waiver service billing is the same as all Medicaid billing. Claims will be subject to the same adjudication process, which involves prepayment edits for third party billing. If a waiver participant has third party coverage in the system and a waiver provider tries to submit a bill to Medicaid prior to billing the third party, an edit will prevent the waiver provider from receiving payment.
If it was found that a claim was paid prior to the input of third party insurance information, the State will pursue retroactive recovery of funds from the potentially liable third party insurance.
The Explanation of Medical Benefits (EOMB) process is designed to inform waiver participants of services provided to them according to Medicaid records and to verify that services billed by waiver providers were actually delivered. eMedNY provides waiver participants with EOMBs including instructions to communicate any discrepancies. The forms are returned directly to the Department of Health EOMB unit.
EOMBs can be produced for all, or for a random sample of waiver participants who received services. They can also be produced for specific waiver participants, waiver participants who received services from a specified waiver provider, or waiver participants receiving services related to a specified procedure or formulary code. The population of waiver participants who receive EOMBs is dictated by a set of user specified criteria.
To meet this assurance, DOH WMS compiles data received from internal queries, audits of claim detail reports, retrospective record reviews, QMS quarterly reports, OMIG audits, DOH surveys and participant complaints (EOMBs). Data will be analyzed for regional and statewide trends.
Remediation efforts may include additional provider audits by OMIG, DOH provider surveys, audits by DOH WMS, restriction of provider opportunity level (Vendor Hold), and/or termination of Provider Agreements.