payment error rate measurement (perm) · pdf filecycle to review the data processing ......

Payment Error Rate Measurement

(PERM)

FY 2017 Cycle 3 Kick-Off

August 25, 2016

1

• PERM Program Overview

• Claims Data Submission

• FFS and Managed Care Sampling

• FFS Details Data

• State Policy Collection

• Data Processing Reviews

• Medical Records Requests

• Medical Reviews

• Tracking Errors and Responding to Findings

• Improper Payment Rate Reporting

• Next Steps

• PERM Eligibility Component

• Communication and Collaboration

• Available Resources

• Contact Information

Learning Objectives

2

PERM Program Overview

• CMS is required to estimate the amount of improper payments in Medicaid and CHIP annually by the IPIA (now amended by IPERA and IPERIA)

• The goal of PERM is to measure and report an unbiased estimate of the true improper payment rate for Medicaid and CHIP

• Because it is not feasible to verify the accuracy of every Medicaid and CHIP payment, CMS samples a small subset of payments for review and extrapolates the results to the “universe” of payments

• The program is currently operating under the PERM final regulation published in August of 2010

• This cycle will review Medicaid and CHIP payments made in Fiscal Year (FY) 2017 (October 1, 2016 through September 30, 2017)

• The FY 2017 improper payment rates will be reported in November of 2018

3

Claims and Payment Measurement

PERM Program Overview

4

Claims Data Submission

• States must submit valid, complete, and accurate claims universes to the SC

• States have 2 data submission options – must choose by September 15, 2016– Routine PERM

– PERM+ For more information on the submission options, contact

[email protected]

Please note that T-MSIS will not be used for FY17 PERM data submission, although its use is currently being evaluated for the future and CMS will continue to update states on its progress

• An intake meeting is held with each state to discuss– Requirements of PERM claims data submission

– Medicaid and CHIP programs and payment structures

– All data sources and the data collection process for PERM

– Waivers, demonstrations, and other programs in the state

– Any state-specific considerations around staffing structure and processes

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mailto:[email protected]


**New** Additional Intake Meeting

• Separate Data Intake Meetings will focus on required data fields to be included in state submissions, formatting options, file layouts (planned to take place in November)

– States will be required to submit file layouts mapping their data variables in state system(s) to variables requested for PERM prior to the data intake meeting

– The SC will review PERM requirements with the state data team

– In depth review of state file layouts - variable by variable - to confirm correct data is mapped to required and proper fields

– Note challenges/missing information from the state

– Walk through any potential data merging issues with PERM+ states

– Discuss header vs line data submission and payment levels

– Address any PHI/PII concerns

– Introduce PERM SFTP access, setting up credentials, security protocols

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**New** Additional Intake Meeting

• CMS 64/21 Intake Meetings will include the PERM contacts and the state’s

financial staff (planned to take place in October or early November)

– Introduce the CMS 64/21 comparison and reconciliation process, as

part of the PERM program

– Discuss the expected timeline for completion of this process

– Walk through a sample of the financial summary documents that will

be prepared for each state program

– Review the state’s comparison and reconciliation process from the

previous PERM cycle

– Answer any questions that the state staff may have regarding this

process


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• Claims data due dates

• The SC will work with the state to ensure all PERM submission requirements are met each quarter

– Timely communication and efforts early on in the cycle will help the process for subsequent quarters and phases of PERM

– The SC performs a series of quality control checks

– The SC also performs a comparison of PERM data submission to CMS-64/21 reports

Quarter Paid Date Due Date

Quarter 1 October 1 – December 31, 2016 January 15, 2017

Quarter 2 January 1 – March 31, 2017 April 15, 2017

Quarter 3 April 1 – June 30, 2017 July 15, 2017

Quarter 4 July 1 – September 30, 2017 October 15, 2017

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FFS and Managed Care Sampling

• **New** Return to payment stratification for FFS sampling

– In FY 2014, the SC separated claims from four preselected service

types into eight service based strata; the rest of the claims were

separated into three payment-based strata, with the addition of one

zero/denied paid claim stratum

– In FY 2017, the SC will select samples from ten payment strata (with

the addition of a fixed payment stratum) and one zero/denied paid

claim stratum

• State-specific Medicaid and CHIP sample sizes based on FY

2014 results

– Each state will receive its sample size notification on August 31, 2016

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FFS Details Data

• Details data is used to request medical records and conduct medical review for sampled FFS claims

– Submitted by routine PERM states

– SC creates details file for PERM+ states

• As in FY 2014, the SC will hold details intake meetings with routine PERM states to:

– Provide an overview of the details data requirements

– Discuss details intake protocol

• **New** Details intake meeting held with PERM+ states to:

– Review details built by the SC

– Verify information to support medical record request

• The SC performs a series of quality control checks and sends questions on any missing/incomplete/invalid information to the states

• The SC may require regular meetings to resolve data issues if there are significant complications or delays 10

State Policy Collection

• The RC will collect state Medicaid and CHIP policies in order to conduct reviews

• Policies may include rules/regulations, manuals, handbooks, bulletins, updates, notices, clarifications, reminders, fee schedules, codes, etc.

• The RC will download all publically available state policy documents relevant to the medical review of claims and create a master policy list for each state

• The RC submits policy documentation to each state for review and approval– Medical Review/Policy Questionnaire

– Master policy list

• The RC continues policy collection throughout the measurement and validates with the state as appropriate

• All policies for medical review and desk aides for data processing review will be available to states and reviewers in SMERF to access policies used when an error is cited

11

Data Processing Reviews

• RC educational webinars are held with all states in the cycle to review the Data Processing (DP) Review process before starting DP Reviews **New** The RC will also have individual check-in calls with

each state throughout the cycle, as needed

• DP reviews are conducted on each sampled FFS claim, fixed payment, and managed care payment

• The RC validates that the claim was processed correctly based on information found in the state’s claims processing system and provider files

• Reviews can take place on-site at the state or remotely **New** Average on-site review time will increase from 2-4

weeks to 3-8 weeks due to increased sample sizes and review requirements (including ICD-10, FCBC, revalidation, etc.)

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• Data Processing orientation is scheduled with each

state prior to reviews to:

– Review state system(s) questionnaires completed by states

– Review any special programs (waivers, etc.)

– Demonstration of any new systems

– Determine and gather desk aids, manuals, and website links

needed for training DP reviewers

– Discuss remote vs. on-site reviews and establish tentative

dates to begin reviews

– **New** States complete DP checklist in preparation for

DP Reviews


13

• **New** States track pending DP reviews real time

through SMERF and receive automated notices for

overdue pending information needed to complete

reviews

**New** Claims on the P1 list will be converted to errors

after the 31st day of pending with no response from the

state, but documentation can still be submitted until the end

of the cycle, similar to the process for MR1 and MR2

errors

**New** All pending documentation now submitted to RC

centralized office in Rockville, MD


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Recipient ID

Date of Death

Date of Birth/Age

County of Residence

Gender

Citizenship Status

Living Arrangements

Aid category and benefit

plan

Managed Care Enrollment

Rules and History

Patient Liability (share of

costs), if applicable

Medicare and/or other

insurance coverage (TPL)

Eligibility Source System

Verification

DP Review Elements - Recipient

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Name

NPI Number

Active Enrollment

Active License (if required)

Active CLIA (if required)

Type/specialty

Service Location

Sanctions

Suspension Periods

OIG Exclusion List

Risk-based screening of newly enrolled

providers

**New** Provider revalidation – claims

paid after 3/24/16 (unless provider was

notified prior to 3/24/16; then must be

screened by 9/24/16)

**New** Fingerprinting and criminal

background checks for high risk

providers for claims paid after 6/1/2016

or the date of a CMS approved

compliance plan

Verification of Provider Enrollment(only applicable when provider is required to be enrolled)

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Verification of Accurate Payment• Determine whether the claim was filed timely

• Determine compliance with HIPAA 5010 transaction standards

for electronic claims

• **New** Determine if system uses ICD10 codes for claims

with DOS on or after 10/1/2015

• Was the claim for a covered service?

• Was the claim priced accurately based on the Fee Schedule in

effect for the date of service?

• Determine if the claim is a duplicate of a previously paid claim

• Identify, report, and consider any adjustments to the sampled

payment made within 60 days of original payment

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Miscellaneous Payment Information

Prior Authorizations (PA) required under the state’s policies

View and compare scanned images of hard copy claims and

attachments with system information

Payments for “Sister Agencies” that receive pass-through

Federal Financial Participation (FFP)

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Managed Care Capitation Payment

Recipient information

Health Plan information

Capitation Rates per

Health Plan

Geographic Service areas

(county, zip code, etc.)

Rate Cells

Exclusions/Carve Outs

Capitation Payment history

screens

Partial month

coverage/recoupment policy

Roll-Out dates (if staged

implementation was in

effect)

Duplicate

payment/adjustment check

19


20

Error Code Name

DP 1 Duplicate Claim

DP 2 Non-Covered Service/Recipient

DP 3 FFS Payment for a Managed Care Service

DP 4 Third-Party Liability Error

DP 5 Pricing Error

DP 6 System Logic Edit Error

DP 7 Data Entry Error

DP 8 Managed Care Rate Cell Error **New Name**

DP 9 Paid Incorrect Managed Care Rate **New Name**

DP 10 Provider Information/Enrollment Error **New**

DP 11 Claim Filed Untimely **New**

DP 12 Administrative/Other Error

DTD Data Processing Technical Deficiency

Initial FY 2017 PERM Data Processing Error Codes

**New** Expanded qualifiers to more specifically identify reasons for error

Medical Records Requests

• The RC makes initial calls to providers to verify provider information upon

receipt of details files from the SC and notifies state PERM representatives prior

to starting calls to providers

• The RC establishes a point of contact with providers and sends record requests

Providers have 75 days to submit documentation

• The RC makes reminder calls and sends reminder letters on day 30, 45, and 60

until the record is received

If the provider does not respond, the RC sends a non-response letter on day

75 (copied to states in weekly batches)

• If submitted documentation is incomplete, the RC requests additional

documentation The provider has 14 days to submit additional documentation

A reminder call is made and a letter is sent on day 7

If the provider does not respond, the RC sends a non-response letter after 14 days

(copied to states in weekly batches) 21

Medical Records Requests

• **New** Two new letters are sent to providers, when needed Receipt of Incomplete Information letter

Resubmission letter

• **New** All medical record request letters have been made standard to match

all other CMS request letters sent to providers

• **New** The RC will establish an SFTP account for each state in order to

facilitate submission of PHI and make record submission easier overall

• **New** All letters sent to providers are copied to the RC’s SFTP site and made

available for each state

• The RC will accept and review late documentation (submitted past the 75 day

and 14 day timeframe) until the cycle cut-off date (July 15, 2018)

• State involvement is essential in obtaining necessary documentation from

providers

• The RC will attend a series of interactive PERM Provider Education Webinars

hosted by CMS for provider outreach22

Medical Reviews

• Medical Review orientations are held for all cycle states, as part of the RC

Educational Webinars, to include

Medical Review process

Difference Resolution/Appeals process

Medical Review/policy questionnaire

• Conducted only on sampled FFS claims

• Utilizes claims data submitted by states, records submitted by providers, and

collected state policies

• Validates whether the claim was paid correctly by assessing the following

Adherence to states’ guidelines and policies related to the service type

Completeness of medical record documentation to substantiate the claim

Medical necessity of the service provided

Validation that the service was provided as ordered and billed

Claim was correctly coded

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Medical Reviews

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Error Code Name

MR 1 No Documentation

MR 2 Incomplete Documentation **New**

MR 3 Procedure Coding Error

MR 4 Diagnosis Coding Error

MR 5 Unbundling

MR 6 Number of Unit(s) Error

MR 7 Medically Unnecessary Service

MR 8 Policy Violation

MR 9 Inadequate Documentation **New**

MR10 Administrative/Other

MTD Medical Technical Deficiency

Initial FY 2017 PERM Medical Review Error Codes

**New** Expanded qualifiers to more specifically identify reasons for error

Tracking Errors and Responding to Findings

• **New** An RC cycle manager has been added to facilitate state

implementation, confirm readiness prior to on-sites or remote

reviews, provide IT support, and overall reduce state burden

• State Medicaid Error Rate Findings (SMERF) system Track medical records requests

Track medical and data processing reviews

Access SUD, Y-T-D Errors, and Recoveries reports

Request difference resolution and appeals

Access improper payment rates and final findings

• SMERF system orientations are held for all states before records are

requested or Data Processing and Medical Reviews are started

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• **New** The RC has enhanced SMERF 2.0 to be more user-

friendly and have increased functionality

Claims Detail Screen: Enhanced view of providers by type on the provider tab;

realigned Medical Records information on claim look-up in descending order,

with the most recent communication listed at the top of the page

Policy Menu: Policies collected and displayed were enhanced to include

access to DP desk aids and Federal Regulation citations used by reviewers and

states

Reports Menu: Expanded to include DP Pending (P1) reports that are updated

real time to communicate with states on information needed to complete

reviews; PERM alerts will be sent from SMERF to advise states when pended

reviews are past the 14 day response time

Recoveries Menu: Added Final Recovery Status reports that display all

overpayment errors reported on the FEFR report and information on the status

of recoveries


26

• **New** The RC has enhanced SMERF 2.0 to be more user-

friendly and have increased functionality

CAP analysis tab: Provides first level access to MR Error Analysis and DP

Error Analysis; enables users to filter and group MR errors by search results

by Year, Program, Claim Category, Error Code and Qualifiers; for DP errors by

search results by Year, Program, Component, Error Code and Qualifier

Individualized reports: States can select from data elements available which

data are needed for their reports by selecting needed fields in the drop down

menu; standard reports can still be provided as default, if needed

CAP Addendum report (To be added to SMERF 11/2016): States will be able

to track any final error changes made during continued processing and use the

information in developing their CAP response

CAP Interactive Module (To be added to SMERF 9/2017): In the future, states

will be able to develop their CAPs, make revisions, and receive

acknowledgment and approvals from CMS through SMERF; notices will be

sent by the system for each action taken in this module


27


• States receive advanced notice of every DP and MR error identified **New** All DP and MR errors will be cited, increasing the opportunity for

states to identify and correct any issues

• Errors are officially reported to states through Sampling Unit

Disposition (SUD) reports on the 15th and 30th of each month

• The state has 20 business days from the SUD report date to request

a Difference Resolution (DR) States must request difference resolution to re-price partial errors

• States have 10 business days from DR decision to appeal errors to

CMS

• States are required to return the federal share of overpayments

identified on sampled FFS and managed care payments

• States are required to develop a Corrective Action Plan (CAP) to

address each error28

• The official Medicaid and CHIP national rolling

improper rates are reported annually in the Agency

Financial Report (AFR) each November

• Following the posting of the AFR, each state receives

its state-specific improper payment rates and findings

through the Error Rate Notifications, Cycle Summary

Reports, and CAP Templates

• This release of official improper payment rates marks

the beginning of the corrective action process

Improper Payment Rate Reporting

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Next Steps

• August 2016• Complete universe data submission survey by August 15

• FFS and managed care sample sizes verified by August 31st

• September 2016 Communicate decision between PERM+ and routine PERM by September 15

Data submission instructions distributed to states

PERM General Education Webinars

Claims orientations/intake sessions begin

• October – December 2016 Alert Lewin no later than October 1 if DUA is needed for data submission

Claims orientation/intake sessions continue

Prepare for universe data submission

• January 2017 Q1 claims data due January 15

30

• The FY 2017 cycle will not consist of an eligibility component

• State-specific improper payment rates will be calculated based on the FFS and managed care

components– No state-specific PERM eligibility improper payment rates will be calculated

• At the national level, CMS will report comprehensive Medicaid and CHIP improper payment rates

based on the continuing FFS and managed care reviews and a proxy eligibility component improper

payment rate

• Medicaid and CHIP Eligibility Review Pilots have replaced the PERM eligibility component and

MEQC traditional pilots for FY 2014 – FY 2017– All states are required to conduct 5 Medicaid and CHIP eligibility review pilots over the 4 year period

– As stated in the State Health Official (SHO) letter # 15-004, dated October 7, 2015, a Federal ERC will

conduct the Round 5 eligibility reviews for the Cycle 3 states

– The Round 5 eligibility pilots are intended to be a “dry run” of future PERM eligibility reviews

• The ERC will utilize the Cycle 3 states’ quarter 1 FY 2017 PERM cycle FFS/managed care claims

sample to identify cases for eligibility reviews during the Round 5 eligibility pilots

• The ERC will conduct reviews according to guidelines outlined in Standard Operating Procedures

(SOP) drafted and refined during three rounds of the Eligibility Support Contractor (ESC) pilot

studies where Federal contractors conducted state eligibility reviews. Under the SOP, eligibility

reviews are broken in four phases: planning, kick-off, case reviews, and final findings and wrap-up

PERM Eligibility Component and

the Eligibility Review Contractor (ERC)

31

Round 5 Pilots Eligibility Review Phases

32

Phase Description

Planning During the planning phase, the ERC will complete all required agreements with each

state; conduct eligibility review educational webinars; gather state-specific

Medicaid/CHIP eligibility policies, systems, and review process information; and

request and receive system access from each state

Kick-Off In phase two, the ERC will work with the state to collect more detailed information

about the state’s eligibility processes and policies

Case Reviews In phase three, the ERC will be conducting the case reviews and providing findings

to the state; the frequency of findings report submission is weekly or biweekly,

depending on state preference

Final Findings and Wrap-up In the final phase of the pilot, the ERC will present the state with its final findings;

the state is allowed to review the final findings for accuracy and point out any

discrepancies, but it is not allowed to contest any of the final findings, as all case

review findings should have gone through the informal and difference resolution and

appeals process during Phase Three

• The process of using an ERC and the FFS/managed care claims sampling methodology is a

new approach to eligibility reviews for the Cycle 3 states. Thus, it is imperative that Cycle 3

states plan to:

– Collaborate with essential state staff to successfully complete each phase of the pilot and support the

ERC, including Medicaid/CHIP policy staff, eligibility system(s) staff, quality control staff, etc. All

staff should plan to be actively engaged. We recommend that states begin identifying a team of staff

members who will be involved in the pilot as soon as possible and begin coordinating amongst the

various departments in order to prevent delays.

– Be prepared to provide the ERC all information used by the state to make the eligibility determination

that is under review, through direct system access and/or by providing hard copy case file

documentation.

• For more information please visit: http://www.cms.gov/Research-Statistics-Data-and-

Systems/Monitoring-Programs/Medicaid-and-CHIP-

Compliance/PERM/FY2014_FY2016EligibilityReviewPilots-.html

– Additionally, CMS will provide more detailed information regarding the Cycle 3 states

responsibilities in Round 5 of the FY 2014-2017 Medicaid and CHIP Eligibility Review Pilots

– CMS will introduce the ERC next month

• Please submit any questions to the mailbox: [email protected]

PERM Eligibility Component:

Collaboration and Next Steps

33

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/FY2014_FY2016EligibilityReviewPilots-.html


Communication and Collaboration

• FY 2017 PERM Cycle 3 Calls

The cycle calls will occur on the Fourth Tuesday of each

month from 3:00 – 4:00 pm Eastern Time

First cycle call will be held on Tuesday, October 25, 2016

• PERM Technical Advisory Group (TAG)

Quarterly TAG calls as a forum to discuss PERM policy

issues and recommendations to improve the program

Regional TAG reps

• CMS PERM Website

www.cms.gov/PERM

34

http://www.cms.gov/PERM

Additional Available Resources &

CMS Contact

• PERM Manual

• PERM Standard Operating Procedures (SOP) for state staff

Nick Bonomo, FY 2017 Cycle Manager

410-786-8942

[email protected]

35


The Lewin GroupPERM Statistical Contractor

3130 Fairview Park Drive, Suite 500Falls Church, VA 22042

703-269-5500

All PERM correspondence should be directed to Lewin’s central PERM inbox

[email protected]

SC Contact Information

36


Review Contractor: CNI Advantage, LLC

General Mailbox: [email protected]

Brent Wolfingbarger, Project Director

301-339-6224

[email protected]

Mariam Siddiqui, Regulations/Policy Manager

301-339-6211

[email protected]

Susan Carlson, Corporate Monitor

301-987-2181

[email protected]

RC Contact Information

37

Christina Beckley, Data Processing Review Manager

301-987-1114

[email protected]

Monica Dantzler-Thomas, Medical Review Manager

301-339-6234

[email protected]

Bahar Degirmencioglu, Medical Records Manager

301-987-1107

[email protected]








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