New Jersey Medicaid Recovery Audit Contractor
Contract A85103
FREQUENTLY ASKED QUESTIONS
- How far back can the RAC go in reviewing claims?
The RAC can go back 3 years from claim payment date.
- Will the RAC be conducting data mining and if so, will providers receive notice that their claims are being data mined?
The RAC will be conducting ongoing data mining of transactions that were processed by NJ Medicaid or Medicaid Managed Care. Providers will not be notified when their claims are being data mined; they will receive notification when their claim is selected for a review.
- Will the RACaudit all the claims submitted by a facility?
The RAC may look at any claims submitted by a facility. For example,if data mining reveals questionable billing patterns with all the claims submitted by a facility, all the claims submitted by a facility may be audited.
- Will the audits focus only on institutional providers?
No, the focus will include all provider types, including, but not limited tolaboratories, and individual providers such as physicians, therapists, and home health providers.
- Will there be any changes in the process of claims recovery once Medicaid Managed Care is in effect?
RAC will audit providers receiving payment from Medicaid Managed Care Organization (MCO), regardless of whether they are enrolled in the Medicaid program. If audits reveal an overpayment, repayment will be obtained from the Medicaid MCO or the provider.
- What is an automated review?
An automated review is used when improper payments can be identified from claim data elements and well established policies and rules, without examining medical records or other documents.
- What is a complex review?
A complex review requires the examination of medical records or other documents, and may also involve on-site auditing.
- Can I submit records electronically?
Yes. The letter from the RAC will requesting records will state that the RAC will accept provider submissions of electronic records on CD/DVD, secure transmission or fax and how to submit the records.
- How do I sign up to use the provider portal?
Please visit and follow the User Registration instructions.
- Is there a limit to the amount of medical records the RAC may request from me?
No provider shall be required to provide more than 150 medical records in any one request from the contractor, nor shall any provider be required to provide more than 500 medical records in any 3 month period.
- Will the RAC pay for copying medical records?
Federal regulations state that the RAC is not required to pay for copying records.
- How long do I have to respond to a record request?
Provider response to initial request for records letter: 15 calendar days.
- How long does the RAC have to audit after the initial letter?
RAC has60 calendar days from the date the complete records were received.
- What happens if I have a delay in obtaining the requested data or documents?
The provider isresponsible to inform the RAC of the delay and the reason for the delay. If the provider needs an extension it will have to submit the request in writing. Any extension to provide the requested documentation will begranted at the sole discretion ofthe Medicaid Fraud Division of the State Comptroller (MFD).
- Will I have an opportunity to respond to any audit findings?
Yes, a draft audit report will be sent to you. You will have 10 calendar days to respond to a draft audit report to an automated review and 20 calendar days to respond to a draft report of a complex review.
- After I have read the draft report, may I ask for an additional review?
Yes. For automated or complex reviews, the RAC will have an additional 30 calendar days to review the provider’s response to the draft report.
- Will I have an opportunity to respond to the final audit report?
Yes, a provider will have 10 calendar days to respond to a final report of an automated review and 20 calendar days to the final report of a complex review.
- What happens if I disagree with the final audit report?
The RAC will notify the MFD. The MFD will file a notice of claim, giving the provider 20 calendar days to file an appeal with the Office of Administrative Law (OAL). During that 20 day period the provider may ask the MFD for a pre-hearing conference, which will temporarily extend the time to file an appeal with the OAL.
- If I file an appeal or ask for a pre-hearing conference will I still have to pay back the amount of the overpayment in the final report?
If the provider files an appeal or asks for a pre-hearing conference, no recoupment of the overpayment will take place until there is an agreement on the amount of the overpayment between the provider and the MFD or the Office of Administrative Law determines the amount of the overpayment.
- What happens if I fail to respond to a final audit report?
The RAC will notify the MFD and the claims comprising the overpayment will be recovered.
- Can the RAC audit a claim that was audited by someone else?
If the claim that was or is currently being audited by a state or federal agency or a contractor working for a state or federal agency involves the same issue or service then the RAC cannot audit the claim.
- What happens if I fail to respond to a medical record request?
If the requested records are not received within 15 days of the date requested, the RAC will attempt contact the provider. If another 15 days pass without the records being produced or an explanation as to why they have not been produced, the claims involved in the audit will be subject to a technical denial, and the claims will be voided.
- How does the RAC calculate overpayments?
Overpayments occur when a RAC audit determines that claims are either fully or partially denied.
A full denial occurs when the RAC determines that: 1) the submitted service was not reasonable or necessary and no other service (for that type of provider) would have been reasonable and necessary: or 2) no service was provided: or 3) the overpayment amount is the total paid amount for the service in question.
A partial denial occurs when the RAC determines that: 1) The submitted service was not reasonable and necessary, but a lower level of service would have been reasonable and necessary: or 2) the submitted service was upcoded (and a lower level of service was actually performed): or an incorrect code was submitted that caused a higher payment to be made.
- Will providers be paid for underpayments?
Yes, if the RACfinds that a claim was incorrectly billed at a lower level of payment than appropriate. The RAC will not report underpayments to the Division of Medical Assistance and Health Services in situations where the provider failed to include a provided service on a claim. The RAC will not process or report underpayments self-disclosed by providers.
- Will extrapolation be applied to determine the amount of overpayments?
Yes. Where the RAC reviews a sample of claims, the RAC may extrapolate to determine the total amount of the overpayment.
- How will overpayments be recouped?
The preferred method of recoupment for Medicaid paid claims will be the reversal or voiding of claims. When in agreement with the RAC findings, providers are instructed to void or adjust their claim in the NJMMIS system maintained by Molina. This adjustment/void process is the same as the process that the provider uses in any other situation when a claim needs to be voided/adjusted. Some provider use an electronic process, others may opt for the FD-999 hard-copy form. The RAC will be monitoring the NJMMIS to validate the accuracy and timeliness of the providers’ claim correction.
In certain situation refund checks will be accepted and tied to specific line-item claims when possible.
Overpayment for Medicaid Managed Care services will be recovered either from the Medicaid MCO or via checks from the provider.
- Will interest be charged when payment is not made in full?
Yes, if interest is charged it will accrue from the date of the final determination and will be charged on the overpayment balance for each full 30 day period that payment is delayed. Payments will first be applied to interest and then principal.
- Will the RAC provide education if I want to understand more fully the billing errors that it determines resulted in an overpayment?
Yes, each overpayment notice will include detailed description of the error and will also include an offer by the RAC to provide education with respect to the billing errors that were found. Education may be offered by written correspondence, telephone conference, webinar, or in person.
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