Chief Patron: Hamilton
Medicaid Audit Improvements (language only)

Item 316 #1h

Language
Page 306, after line 52, insert:
"E.1.

As a condition of this appropriation, the Department of Medical Assistance Services (DMAS) shall develop and implement a written plan to include procedures for audits of providers of community mental health, mental retardation and substance abuse services furnished under the State Plan for Medical Assistance conducted directly, through the Office of the Attorney General, or through a contract with any other entity, pursuant to §32.1-320, Code of Virginia.  This plan shall include, but shall not be limited to, provisions to cover the following: clear and specific guidelines to providers through published manuals and memoranda pertaining to covered services and requirements for reimbursement; availability and provision of DMAS training for providers relating to covered services and requirements for reimbursement; a mechanism for providers to receive timely written answers to questions during service delivery or claims processing; a mechanism for informing providers before and during the audit process as to the specific documents to be made available for purposes of the audit; the alternative use of reasonable civil penalties in instances of ministerial or documentation errors not involving the nondelivery of services; use of a stratified or other scientifically valid method of statistical random sampling of equal or greater validity for auditing claims where an extrapolation methodology may be required for the computation of overpayments due to the high volume of claims involved; in instances where the provider is responsible for the state share of any reimbursement, a procedure limiting the recovery to the federal share of the reimbursement; in instances where the provider is not responsible for any portion of the reimbursement, a procedure for recovery of the entire reimbursement; and procedures for the consideration and implementation of reasonable written comments and concerns submitted by providers.

2. In the development and implementation of this plan, the Department shall solicit and consider comments and suggestions from all Medicaid providers.   The Department shall complete and submit this plan to the House Appropriations and Senate Finance Committees, along with a summary of the written comments and suggestions from all Medicaid providers,  no later than October 15, 2001.  Thereafter, the Department shall not implement this plan until the expiration of the 30-day period following the stated submission.  Prior to the implementation of this plan, the Department is prohibited from employing, and shall suspend the use of, any extrapolation methodology to determine overpayments resulting from any audit which may be the subject of an administrative or court appeal which has not been resolved by a final nonappealable order or agreement, or with regard to any other audits performed prior to the date of the implementation of this plan."
Accompanying Budget  “The Department of Medical Assistance Services shall develop a mechanism for automatic future adjustments in the personal care reimbursement rate.  The Department shall submit a report outlining the proposed mechanism and the estimated fiscal impact to the Governor, the Chairmen of the Senate Finance Committee, the House Appropriations Committee, and the Joint Commission on Health Care prior to November 1, 2000.”

Explanation
Personal care services help at-home patients with the tasks of daily living as an alternative to costlier institutional care such as a nursing home. The introduced budget includes $2,000,000 (GF) and $2,200,000 (NGF) in both years to fund a $.50 increase in the personal care reimbursement rate paid by Medicaid. This amendment requests an additional $2,000,000 (GF) and $2,200,000 (NGF) in both years to fund an additional $.50 increase in the rate. (The overall increase would be $1.00/hour raising the current rate from $10.50/hour ($12.50/hour in Northern Virginia) to $11.50/hour ($13.50/hour in Northern Virginia). An accompanying language amendment directs the Department of Medical Assistance Services to develop a mechanism for automatic future adjustments to the rate.