Provider Notice issued 08/26/09

Payment Error Rate Measurement (PERM) Audit Record Requirements Reminder

Federal CMS hired contractors to sample and review services paid by HFS within FFY 2009, which included collection and review of medical records to determine whether a correct payment was made.  After collection and review of sample services paid by HFS, PERM auditors noted concerns regarding incomplete documentation maintained in participant’s medical records. 

Based on these concerns, the following serves as a reminder of the record requirements established by the department.

Maintenance of Records

• Providers are to maintain the following records: Any and all business records which may indicate financial arrangements between the provider and other providers in the program or other entities, or which are necessary to determine compliance with federal and state requirements, including, but not limited to:

• business ledgers of all transactions;

• records of all payments received, including cash;

• records of all payments made, including cash;

• corporate papers, including stock record books and minute books;

• records of all arrangements and payments related in any way to the leasing of real estate or personal property, including any equipment;

• records of all accounts receivable and payable; and

• original signed billing certification forms for each voucher received.

Any and all professional records which relate to the quality of care given by the provider or which document the care for which payment is claimed, including, but not limited to:

• medical records for applicants and participants in the Department’s Medical Programs (copies of claims alone will not meet this requirement), including a record of ancillary services ordered as a result of medical care rendered by the provider; and

• other professional records required to be maintained by applicable federal or state law or regulations.

The business and professional records required to be maintained are to be kept in accordance with accepted business and accounting practice and are to be legible.

Professional records documenting the history, diagnosis, treatment services, etc., of a Medical Assistance, Moms and Babies, All Kids, FamilyCare, Illinois Cares Rx, Veterans Care, Health Benefits for Workers with Disabilities, Transitional Assistance or State Family and Children Assistance patient are to be made available to other healthcare providers who are treating or serving the patient, without charge and in a timely manner, when authorized by the patient in writing.

Retention of Records

Business and professional records must be maintained for a period of not less than three (3) years from the date of service or as otherwise provided by applicable state law, whichever period is longer, except that:

• if an audit is initiated within the required retention period, the records must be retained until the audit is completed and every exception resolved, and

• original signed billing certifications for every voucher received are to be retained not less than three (3) years from the date of the voucher.

Availability of Records

All records required are to be available for inspection, audit and copying (including photocopying) by authorized Department personnel or designees during normal business hours. Such personnel or designees may include but are not limited to the Department’s Office of Inspector General, representatives of the Medicaid Fraud Control Unit, law enforcement personnel, the Office of the Auditor General, and the federal Centers for Medicare and Medicaid Services (CMS). Such personnel or designees shall make all attempts to examine such records with minimal disruption to the professional activities of the provider.

The provider’s business and professional records for at least twelve (12) previous calendar months are to be maintained available for inspection without prior notice by authorized Department personnel or designee on the premises of the provider. Department personnel shall make requests in writing to inspect records more than twelve (12) months old at least two (2) days in advance of the date they must be produced.

The record requirements listed above are applicable to all providers.  Providers are encouraged to refer to the appropriate Chapter 200 handbook for any additional provider specific requirements.  Several Chapter 200 handbooks are available on the department’s Web site.  Copies of handbooks not available on the Web site may be requested from the Provider Participation Unit at 217-782-0538.

As the PERM program continues, the department is requesting your cooperation with submitting all requested documentation in a timely manner.  If one of your services is randomly selected for review, a representative from the CMS contractor will initially call your facility to establish a point of contact and then follow up with a written request for records.  The HFS Office of Inspector General will also contact you about supplying the requested information. You will have sixty (60) days to provide this documentation.  It is imperative that you provide this information. Failure to comply with this request will result in an erroneous payment finding and payment recovery.  

Questions regarding this notice may be directed to the Bureau of Comprehensive Health Services at 1-877-782-5565.

Theresa A. Eagleson, Administrator

Division of Medical Program