Medicaid Retrospective Claims Program

What you should know about M-RAPE

(Re-Posted from 2 weeks ago)

I have decided to re-name the Medicaid retrospective claim review project to M-RAPE (Medicaid Retrospective Administrative Payment Execution), as theoretically the powers to be at Iowa Medicaid program are doing a pretty good job of financially raping the provider community with this project.

As you all should know, Iowa Medicaid had decided to adopt CCI edits in 2010 and then re-process all claims which were paid and closed – going back to 2007!

I feel it’s important to share the information I sent the State on behalf of Iowa Providers so that by the time you have digested all of this information, you can make your own informed decision on how to proceed for your individual practices. As a disclaimer, the views and opinions presented in this document are solely those of the this author. I do however, give you permission to use any portion of this information in your own appeals to Iowa Medicaid, and do encourage you to appeal. I apologize for the length of this e-alert, but there is much information to share.

On March 2, 2011 – I wrote to Jennifer Vermeer, Director of the Medicaid program as well as Senator Jack Hatch, Representative Dave Heaton, DHS Director Charles Palmer, and Michael Bousselot of the Governor’s Office. :

“This letter was in reply to our letter which objected to most of your retrospective claim review project. We felt that re-processing claims based on policy and procedures not in effect at the time of payment was unusual, uncommon, and perhaps illegal. It would relate to issuing speeding tickets to everyone who drove 70 MPH on the Interstate in 2007, 2008, 2009, and2010 because in 2011, the State lowered the speed limit to 60 MPH.

I would concur that CCI edits have been part of the Medicare program for some time, your need for Iowa Medicaid to implement CCI is quite understandable and as I have mentioned before, _____ did not have issue with this implementation, based on your intent to implement. What we did and still do have issue with, along with other Iowa Medical Associations, is the fact that your intent was to apply those edits retrospectively to claims appropriately paid, based on your edits and policy at the time of service. You assert that Iowa Code 249A.5(1) gives the Department the right to recover claims paid in error. I agree, but also believe that applies to claims paid in error using the POLICY IN FORCE AT THE TIME OF SERVICE,NOT A PAYMENT POLICY APPLIED RETROACTIVELY TWO YEARS after the fact.

The paragraph titled "Our Policies Remain Consistent", doesn't appear to be necessarily accurate. As an example, one office shared an example where there recoupment letter stated that 36416 is not payable separately and yet the 2007 BILLING OF MEDICAL SERVICES guide distributed at Provider Training, page 38 indicates that 36416 is payable. Are you unaware of the conflicting policy?

You reference Info Letter 875, which indicates how Medicaid will start using CCI edits and Medicare bundling rules, etc. It appears that these concepts were not communicated to providers as Medicaid policy until the publication of Info Letter 875. I refer again back to the 2007 BILLING OF MEDICAL SERVICES guide, which was the Medicaid policy guidance until Info Letter 875, and the rules that are now in conflict with Info Letter 875. Please provide me with proof of guidance between the dates of publication of these two documents (2007 Billing Guide and Info Letter875) , where Medicaid informed providers that Medicare bundling and coding rules and Medicare Fee Schedule status B indicators would be applied to claims. The 2007 Billing Guide does not address the polices that Medicaid is now applying retroactively as the result of the adoption of the CCI edits (see Info Letter 875) Providers use the Medicaid Provider Manuals, Informational letters and Provider Training Material as Medicaid Policy guidance.

If providers are to be using another source for Medicaid policy guidance, please direct me to those sources, other than Info Letter 875. As you have been previously notified, Iowa Medicaid did not implement CCI edits prior to 2010. Any failure to implement CCI edits or special bundling policies that occurred was the failure of Iowa Medicaid, not physicians who submitted claims consistent with Medicaid rules in place at the time of submission.

Providers can not be submitted to recoupment based on rules NOT in effect at the time of service. You appropriately paid claims in accordance with your own requirements then in place. Your system would have and could have rejected inappropriate claims that did not comply with your billing policies prior to the implementation of the CCI edits. The reimbursement of E&M codes incorrectly billed may be appropriate to recoup based on review of the situation, but your requests for other monies to be returned I believe is still not permissible.

On behalf of our members, representing over 4,000 providers, you are again asked to issue a letter of correction and to cease your efforts to receive back monies correctly paid to providers based on the guidelines in place at the time of service. I look forward to a prompt reply.” Mitch Harris

To this, on March 17, 2010, Jennifer Vermeer replied:

“Dear Mitch, Thank you for your note. As requested in my previous letter to you, any concerns with a Program Integrity audit result should be addressed through the existing process described in the letter you received that defines the audit findings. Your peers at the Iowa Medical Society are recommending their members follow that process also (see http://www.iowamedical.org/news_detail.cfm?newsID=413 ). This process allows us to fully review all of the specifics for each case to make a consistent decision affecting all similar cases. In implementing this project, we reviewed the test data and policies carefully before moving the audit into production. We understand that in executing a review of this scope and complexity, there could be specific items we may need to re-consider with additional information. This is exactly why there is a defined process for resolution of any specific items at issue. We always consider the balance of our responsibility to ensure appropriate use of the public's program dollars against how oversight activities might impact our provider community. Regarding the specific issue you point to around procedure code 36416, I can let you know that IME has reviewed that concern as it was raised through the regular process (there was a similar one also raised around procedure code 99000). A decision was made recently that both those codes (36416 and 99000) will be excluded from the recovery. In many cases, amended letters have already been sent to notify the affected providers; all such letters should be sent by the end of next week at the latest. I hope that addresses your concerns. Please contact Bob Schlueter or Brian Fisher if you have any further questions. Sincerely, Jennifer Vermeer”

So….from her reply, it appears that some providers who were really paying attention found some definite “flaws” in their edits that were contrary to Medicaid own policy! Hence, they have relaxed those edits. As you review the M-RAPE material sent to you from Medicaid, be a detective. Since all of my concerns were not answers, I wrote back…

On March 20, 2011…

Good Morning Jennifer, et al: Thank you for your reply and I will be issuing an article to ____ membership in the next day or so.

Your reply neglected to provide any answer to the following request in my initial letter:

"I refer again back to the 2007 BILLING OF MEDICAL SERVICES guide which was the Medicaid policy guidance until Info Letter 875, and the rules that are now in conflict with Info Letter 875. Please provide me with proof of guidance between the dates of publication of these two documents (2007 Billing Guide and Info Letter875) , where Medicaid informed providers that Medicare bundling and coding rules and Medicare Fee Schedule status B indicators would be applied to claims. The 2007 Billing Guide does not address the polices that Medicaid is now applying

retroactively as the result of the adoption of the CCI edits (see Info Letter 875) Providers use the Medicaid Provider Manuals, Informational letters and Provider Training Material as Medicaid Policy guidance"

Can you please provide an answer to the information requested above.

Thank you. Mitch Harris

On March 22, 2010, I received this back…

Hi Mitch,

As always, per 441 IAC 79.9(1): absent expressed policy otherwise, Medicaid follows Medicare.

In the case of procedure codes 36416 and 99000 there was specific policy communication we could point to, and those codes have been excluded from the recovery for that reason.

If there is specific guidance from the time indicating Medicaid was not following Medicare on bundling/coding rules and status B indicators to which you refer (your basis for not following the Medicare policy), it would be considered. We are not aware of such guidance.

Bob Schlueter IME Provider Services

I reviewed first, 441-79.9 which is the heading reads: “General provisions for Medicaid coverage applicable to all Medicaid providers and services.”

79.9(1) reads: “Medicare definitions and policies shall apply to services provided unless specifically defined differently.

My interpretation of the heading and sub section (1) I believe pertains to “services provided” and NOT billing guidelines. I believe that Iowa Medicaid is grabbing at straws trying to use this Iowa Administrative Code inappropriately to help them justify their actions with M-RAPE. In addition, the IAC reference above has always been kind of ambiguous. Medicaid’s 2007 billing guide does not even reference the IAC citation. This citation is also not referenced in the Physicians Provider Manual. If this citation is so important to the point that they are trying to hide behind it as an excuse for M-RAPE, why has Iowa Medicaid never made any effort to convey this IAC rule to providers?

It does look to me that Iowa Medicaid is “trying” to work with providers, they admit that due to the scope and complexities of M-RAPE, they are willing to accept appeals. Providers should not feel like they are being forced to re-pay claims that were appropriately billed. I wrote in my appeal letter that my “claims were appropriately submitted and paid based on the billing procedures you had in place at the time of services. Seeking to recoup monies based on billing procedures that were not in place at the time of service, I believe is illegal and unethical.”

I hope that every provider office has reviewed the information sent to them and has responded to Iowa Medicaid. If you have codes that other carriers are paying for and Medicaid has decided, due to the new CCI edits, that they should be denying….those codes are probably inappropriate for them to try and recoup. Medicaid is forcing providers to jump through hoops (and jump quickly), they require you follow their unreasonable time frames for response. They require you reply initially within 15 days of the date of their letter, even though it takes up to 5 days from the date of their letter before you receive it at your door…

You are urged to contact the Governor and your local State Senators and Representatives as well as Representative Dave Heaton and Senator Jack Hatch who provider oversight to the Medicaid finance program. This M-RAPE program isn’t right, it’s not even close to being right.

I have provided much information in this writing to assist you in your appeal process. I personally am prepared to take my appeal, if necessary to the Administrative Law Judge. A class action law suit is not out of the question here…something to think about…

Medicaid is the lowest payor and requires the most from us administratively….they have a lot of nerve trying to M-RAPE us!

Mitch