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Provider Notice Issued 02/15/2018
Date: February 15, 2018
To: Participating Medical Assistance Program Providers
Re: Payment Error Rate Measurement (PERM) Audit
To comply with the Improper Payments Information Act of 2002, the federal Department of Health and Human Services, Center for Medicare and Medicaid Services (federal CMS) has implemented a Payment Error Rate Measurement (PERM) program, which measures improper payments within each state's Medicaid and Children's Health Insurance Program (CHIP) program. Each state is required to participate in PERM every three (3) years.
The FFY18 PERM period has begun and providers will be contacted to provide records to support the payment review of randomly sampled claims.
This notice serves as a reminder that all services for which charges are made to the Illinois Department of Healthcare and Family Services (the Department) are subject to audit. Audits are an important and necessary part of the Department's monitoring of health care facilities and services, as required by the federal and State law. Audit findings against a provider will result in the recovery of resulting overpayments. Audit findings against a provider may also result in sanctions or other penalties, including but not limited to: (1) termination or suspension of the provider's eligibility to participate as a Medicaid and/or CHIP provider; (2) suspension or denial of the provider's payments; and (3) civil monetary penalties.
FFY 2015 PERM Review
The previous PERM (FFY15) conducted by the federal government resulted in the following errors being identified: (1) no documentation; (2) incomplete documentation; (3) inadequate documentation; (4) procedure or diagnosis code incorrect; (5) National Provider Identifier missing on claim.
No Documentation
- Provider did not respond to the request for records.
- Provider did not have the participant on file or in the system.
- Provider stated that the participant was not seen on the sampled date of service.
- Provider submitted a record for the wrong date of service.
Incomplete Documentation
- Multiple documents were missing from the record that is required to support the payment.
- Provider did not submit a record with daily documentation of specific tasks to support the payment.
- Provider did not submit the signature log and/or documentation of patient counseling.
- Record did not include an order for the sampled service.
- Individual plan was available but not applicable to the sample date of service.
- Provider did not submit a record with daily documentation of specific tasks performed on the sampled date of service.
- Provider did not submit required progress notes applicable to the sampled date of service.
- Provider did not submit the service plan.
Inadequate Documentation
- Orders were signed and dated after the sample date of service.
Ø Corrective Action to Address the Missing, Incomplete, and Inadequate Documentation Errors: Providers are to follow the policy and procedures issued in the general handbook for all providers, Chapter 100 – General Policy and Procedures, Topic 110 - Record Requirements, subtopics 110.1 to 110.3 - Maintenance, Retention and Availability of Records.
Procedure or Diagnosis Code was Incorrect
- The provider documented an evaluation, but billed for a treatment.
Ø Corrective Action to Address Proper Billing Related to Procedure or Diagnosis Codes: Providers should refer to their specific handbook in the Chapter 200 series of handbooks.
National Provider Identifier (NPI) Missing on Claim
- Attending provider NPI required, but not submitted on institutional claim.
- Referring/ordering/prescribing provider NPI not listed on claim.
Ø Corrective Action Regarding NPI Requirements: Hospital providers should refer to the Handbook for Hospital Services in the Chapter 200 series of handbooks regarding the Attending provider NPI requirements.
42 CFR 455.440 requires that all claims for services that were ordered or referred contain the NPI of the physician or other professional who ordered or referred such services. 42 CFR 455.410 further requires that those ordering or referring physicians or other professionals be enrolled as participating providers.
As a result, HFS will mandate any services that require an order/referral to have an individual practitioner’s NPI included on the claim. Ordering/referring practitioners (ORP) will be required to enroll in IMPACT if they have not already done so. The ORP must be an individual and cannot be an entity. Please ensure all ORP are enrolled, as in the future, claims that require an ORP will be rejected if the enrolled ORP is not included on the claim. Additional information, including the effective date of this requirement, will be communicated in a future notice.
Additional information related to NPI requirements can be found in Chapter 100 – General Policy and Procedures, Topic 101 - Provider Enrollment, subtopics 101.1 - Illinois Medicaid Program Advanced Cloud Technology (IMPACT) and 101.2 - Prerequisite Enrollment Steps for Providers.
Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 877-782-5565.
Felicia F. Norwood
Director