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on behalf of the agency for health care administration welcome to this training on compliance tips for Florida Medicaid providers the Florida Medicaid program is offering this training as an opportunity to increase your understanding of program compliance as well as your understanding of the value of keeping informed on Medicaid policy this is an overview of compliance related issues and will assist new providers with basic Medicaid compliance tips and will also serve as a refresher for existing providers we also want to assist all providers in your efforts to improve compliance the objectives of this training are to share basic Florida Medicaid compliance tips that might seem obvious but are common areas of non-compliance that we would like to make sure our new Florida Medicaid providers are aware of and are actively taking steps to avoid we also want to refresh current Florida Medicaid providers on basic Medicaid compliance information and remind you to also take steps to ensure you are following the program rules it is our goal to assist all providers in improving compliance with Florida Medicaid policy throughout this training we may refer to the agency for health care administration as simply the agency kocca this presentation is divided into six sections section one addresses the Florida Medicaid provider handbooks section two will cover licensure and certification issues for Medicaid providers section three will highlight required changes to provider enrollment files in section four we will provide information about records inspection and in section five we will share information about additional resources for Florida Medicaid providers and finally the sixth section will conclude the training presentation with a summary let's begin by talking about the Florida Medicaid handbooks Medicaid providers should consider the three types of Florida Medicaid handbooks that exist these handbooks contain many of the requirements for providers to remain compliant with the program's policies the handbooks are essential for a provider to ensure that they know where to find the policies that govern their practice and their billing first is the provider general handbook which is relevant to all providers second are the coverage and limitations handbook which are specific to particular provider types and services this means that there are several coverage and limitations handbooks a provider should be familiar with the coverage and limitations handbook or books that relate to the types of goods or services that they furnish and finally there are reimbursement handbooks which are also relative to the provider type but specific to whether you are an institutional provider or a non institutional provider these handbooks address how to get paid providers should become familiar with each of these handbooks the Medicaid handbooks are critical for you as a provider they document the policies and procedures needed to receive reimbursement and ensure that goods or services are furnished in accordance with policy while the handbooks are not the only laws that providers are required to comply with they are the provisions that are most often the subject of agency initiated audits the handbooks provide detailed descriptions and instructions about how and when to complete forms letters and other documentation necessary for full compliance and appropriate reimbursement from the Medicaid program the Florida Medicaid provider general handbook contains general information for providers it provides an explanation of the Florida Medicaid program and policies and is an essential foundation for all new providers it provides information that will help providers ensure that they are only billing for services for eligible recipients and that they are knowledgeable about provider enrollment issues which are critical to ensuring their continued participation in the program the provider general handbook also contains provider eligibility requirements that must be maintained to ensure continued eligibility to participate in the program it has a chapter on cross over payments and has a chapter about Medicaid fraud and abuse that highlights the agency's program integrity efforts the coverage in limitations Handbook explained covered services and policies for each type of Medicaid service the handbooks explain the details about what the Medicaid program will pay for they also explain the policy limitations exclusions and procedure codes the handbooks also provide descriptions and instructions on how to and win to complete forms that are required for particular services and provide details about the programs required documentation for particular services a provider who furnishes more than one type of service will have more than one coverage and limitations handbook the reimbursement handbooks provide necessary guidance for billing the Medicaid program each reimbursement handbook is named for the corresponding claim form and explains how to complete and file claims for reimbursement from Medicaid they also contain generic eligibility information general Medicaid information and claim instructions as we've explained previously it is critical that the Florida Medicaid providers follow Medicaid policy in all three types of handbooks providers who understand the relationship between the Florida Medicaid provider general handbook the service specific coverage and limitations handbook that governs their practice and the Florida Medicaid provider reimbursement handbook can increase the effectiveness of their internal compliance efforts all Florida Medicaid handbooks fee schedules forms provider notices and other important Medicaid information are available on the Medicaid fiscal agents web portal and HTTP colon forward slash forward slash my Medicaid - florida.com forward slash the Florida Medicaid web portal solution provides communication data exchange and self-service tools to the provider community the web portal consists of both public and secure areas those web pages will require a username and password for access for your security the public area contains general information such as program awareness notices and forms for section two of the presentation let's continue our discussion and talk about licensure and certification each medicaid applicant in-state and those who are out of state must sign a Medicaid provider agreement that affirms compliance with all laws and rules governing the delivery and reimbursement of services or goods to Medicaid recipients the applicant is also responsible for its employee and contract ease maintaining compliance with the terms of the agreement please also remember that the Medicaid provider shall possess at the time of signing of the Medicaid provider agreement and maintaining good standing throughout the period of the agreements effectiveness a valid professional occupational now commonly known as the business tax receipt facility or other license pertinent to the services or goods being provided as required by the state or locality in which the provider is located and the federal government if applicable the business tax receipt is proof of payment of the business tax it is required before a business opens or starts a business operating without a business tax receipt is subject to a penalty health care practitioners must be actively licensed to practice as required in the applicable coverage and limitations handbook to enroll is Medicaid providers and to remain enrolled please be aware that Medicaid will terminate providers who fail to maintain professional licensure effective the date that the license was terminated if a provider continues to receive payment for services rendered after his license has expired the payments will be subject to recoupment the provider may also be subject to sanctions and referred for further review to other agencies including the Attorney General's Medicaid fraud control unit for such issues as unlicensed practices or suspected fraud for billing for services that require a license which were rendered by unlicensed personnel the agency's division of Health Quality Assurance sometimes referred to simply as HQ a protects Floridians through oversight of health care providers HQ a licenses and/or certifies and regulates 40 different types of health care providers including hospitals nursing homes assisted living facilities and home health agencies in total the division licenses certifies regulates or provides exemptions for more than 42,000 providers the Medicaid fiscal agent periodically compares the provider license file to the Department of Health's health care practitioner license files and to the HQ a facility license files the Department of Health is commonly referred to as do H if a Medicaid providers licensure information is missing from the provider enrollment file or does not match an active number on the do H or H QA licensure file the provider may be disenrolled from the Medicaid program the failure to maintain required licenses can also result in sanctions from the Medicaid program the following providers must be Medicare certified in order to enroll as Medicaid providers and to remain enrolled ambulatory surgical centers free-standing dialysis centers hospices hospitals rural health clinics portable x-ray providers home health agencies and skilled nursing facilities must be either Medicare certified or meet the standards for certification while acha does not operate the Medicare program the staff and hqa conduct the medicare surveys to determine if the facility is in compliance with the Medicare certification standards Medicaid regularly receives certification information from HQ a Medicaid will terminate providers who fail to maintain standards of certification effective the date of the Medicare termination if the Florida Medicaid provider continues to receive payment for services rendered after it is no longer in compliance with the Medicare certification standards the payments are subject to recoupment the provider may also be subject to sanction and referred for further review to other agencies including the Attorney General's Medicaid fraud control unit an excellent resource for providers is the agency's website which is located at HTTP colon forward slash forward slash a HCA a Florida comm /mc HQ forward slash index dot s HTML on the HQ a home page office division of HQ a consists of five bureaus the Bureau of field operations the Bureau of health facility regulation the Bureau of long-term care services the bureau of managed healthcare and the bureau of plans and construction the bureau of field operation is responsible for completing on-site surveys to determine compliance with state licensure requirements and compliance with federal certification requirements for certified facilities and for handling consumer complaints the Bureau of health facility regulations handles healthcare licensure Medicare and Medicaid certification and regulation for hospitals ambulatory surgical centers home health agencies hospices clinical laboratories and over twenty other types of healthcare providers the bureau also contains the certificate of need which you will often hear referred to as co n Hospital financial analysis programs hospital ambulatory surgical center risk management program and the organ donor education registry program another good resource for licensure and certification resources is the Department of Health's division of medical quality assurance mqa which offers many services to their licensees and healthcare businesses their website is HTTP colon forward slash forward slash ww2 voh dot state FL u.s. /mq a services forward slash working in conjunction with 22 boards and six councils mqa licenses and regulates seven types of facilities and two hundred-plus license types in more than 40 health care professions now let's move on to section 3 where we'll talk about changes to the provider enrollment file providers are required to promptly notify Medicaid of any changes of address having an accurate address on file with the agency ensures accurate communication including prompt payment for services rendered the following four addresses may be housed on the provider file the service address a pay to address a mail to or correspondence address and a home or corporate office address to report a change of address providers must obtain and complete the Medicaid provider change of address request acha form 2200 - zero zero zero four dated July 2008 the form is available by calling the provider contact center at one eight hundred to eight nine seven seven nine nine and selecting option for the form is also available from the Medicaid fiscal agents web portal at HTTP colon forward slash forward slash my Medicaid - Florida select secure information for providers then demographic maintenance and then location name address if first-class mail to a provider's service address is returned Medicaid will suspend claims payments to the provider or the providers group for services rendered by that provider after 90 days the suspended claims will be denied if the provider has not taken the corrective action to update their address this action by the agency has an impact on the providers payments so please be very diligent in reporting changes of address another common error that has adverse consequences for providers is when a group moves and updates the group's address but forgets to update the addresses for each of the individuals who participate in that group should the agency need to communicate with an individual member of the group and the address hasn't been updated the individual member could be terminated due to the bed address this would have adverse implications for both the individual provider as well as the group provider individual or group providers who render services at more than one service address under a single license or certification are required to submit a new location request form to identify each separate physical address where services are provided also please remember in order to report a change of address the provider must obtain and complete the Medicaid provider change of address request form the form is available from the Medicaid fiscal agents web portal at HTTP colon forward slash forward slash my Medicaid - Florida comm select secure information for providers then demographic maintenance and location name address you may also call the provider contact center at one eight hundred to eight nine seven seven nine nine and select option four to request the form for those individual or group providers to provide only one type of service but are uniquely licensed or certified for each location you are required to submit a separate Florida Medicaid provider enrollment application to obtain a unique Medicaid identification suffix for each location you'll also want to be aware that any closure of a provider's practice address must also be reported to the fiscal agent along with the effective date of the closure this is a reminder that in Section P of the Medicaid provider agreement providers agree to notify the agency of any changes to the information furnished on the Florida Medicaid provider enrollment application including changes of address tax identification number group affiliation depository bank account and principals failure to promptly notify Medicaid about office closures can adversely impact a provider with regard to any subsequent provider enrollment applications Florida Statutes define a change of ownership as an event in which the provider changes to a different legal entity from which 51% or more of the ownership voting shares or controlling interest in a corporation whose shares are not publicly traded on a recognized stock exchange is transferred or assigned including the final transfer or assignment of multiple transfers or assignments over a two-year period that cumulative Lea total 51% or more a change solely in the management company or board of directors is not a change of ownership per Section four zero nine point nine zero seven parent six of the Florida Statutes at least 60 days before the anticipated date of a change of ownership the transfer or is required to notify akka of the intended change of ownership and the transferee is required to submit a medicaid provider enrollment application if a change of ownership occurs without compliance according to the notice requirements both the transfer or and the transferee are liable for overpayments administrative fines and other monies due to akka changes of ownership are oftentimes referred to by the acronym CH o W or Chow before a Chow application may be granted akka may require the transferee or transfer or to repay all outstanding overpayments administrative funds and other monies due to acha acha may also seek any other legal or equitable remedies available to recover monies owed to the Medicaid program again this means that both the transfer or and the transferee have obligations to ensure compliance and both parties may be liable if compliance is not achieved bear in mind that when you sign the Medicaid agreement you agreed to notify the agency of any changes to the information furnished on the florida medicaid provider enrollment application including changes regarding your tax identification number if a provider's tax identification number changes the Medicaid provider ID must be terminated and the new Medicaid provider ID must be established for the new entity if the change to the tax ID is due to a change in ownership then the procedures for a change in ownership must be followed the fiscal agent may change a tax identification number only under the following circumstances the provider submits a copy of the IRS form letter indicating the providers new tax identification number or the provider acquires an existing company and request that its tax identification number be changed to the existing providers own tax identification number let's talk a bit about federal tax identification numbers or fine numbers as they are also known and how they affect provider IDs there are some instances where the providers authorship changes and the tax identification number will remain the same keep in mind though that whenever the ownership does change the Medicaid provider ID must be terminated and the new Medicaid provider ID must be established it is very important that you report any changes in telephone numbers to the Medicaid fiscal agent except for a change of address information about a provider can only be changed by the provider submitting a written signed and data request on letterhead stationery the request must be signed by an authorized person on the provider file the Medicaid provider ID must be included notice of a change in telephone number or numbers must include the new telephone number or numbers and the providers previous telephone number or none providers who participate in Medicare are required to notify the agency within five business days after suspension or disenrollment from Medicare tell you to notify akka may result in sanctions being imposed and the provider may be required to return funds paid during the period of time that the provider was suspended or disenrolled as a Medicare provider Medicaid will immediately terminate providers who are suspended excluded or terminated from Medicare or any other state's Medicaid program the effective date of the termination will be the date that the provider was suspended excluded or terminated from the Medicaid or Medicare program at this point in our presentation we'll discuss a few final areas of significance regarding provider enrollment files when an individual member joins or leaves the group either the group provider or the individual member must report the change to add an individual to a group send a letter to the fiscal agent the letter must include the group's provider identification number the individual's provider identification number and the date the individual joined the group this letter must be signed by the individual provider to remove an individual from a group's membership you'll also need to send a letter to the fiscal agent the letter must include the group's provider identification number the individuals provider identification number and the date the individual left the group the letter to remove an individual from a group may be signed by either the group or the individual provider the individual needs to submit a change of address form when they leave a group if the group's address remains on the individuals provider file the mail will continue to go to the old group's address as we previously explained this can have adverse consequences for the provider let's talk about electronic funds transfers automatic deposits and payments to provide some clarification information on the automatic deposits and payments or EFT record can only be changed by authorized individuals a new EFT form must be completed and submitted to the fiscal agent by individuals who are listed on the current provider file as having authorization to sign on the providers bank account the new EFT form must contain an original signature or signatures the provider ID and must be accompanied by a letter from the Depository branch verifying the name on the account the account number and the routing or transmittal number a significant resource for Medicaid providers is the Florida Medicaid fiscal agent the fiscal agent enrolls non-institutional providers processes claims and distributes medicaid forms and publications general provider and recipient information can be found on the florida medicaid's web portal for provider specific information visit the provider web portal and for recipient specific information visit the recipient web portal the Medicaid fiscal agent web portal provides communication data exchange and self-service tools to the provider community the portal consists of both public and secure areas web pages requiring a username and password the public area contains general information such as program awareness notices and forms and allows users to respond to surveys and the portal secure area providers can access their personal information using their provider numbers and pins personal identification numbers providers can update information on the provider number update address information request eligibility verifications request and track prior authorizations and referrals submit and track claims receive alerts and notices and receive Medicaid policy updates for important resource information please visit the Medicaid web portal located at my Medicaid - Florida comm located here under the public information for providers link you can find the contact us link that provides important contact information the automated voice response system number or a VRS is 1-800 two three nine seven five six zero the provider services main number is six six five eight six zero nine six one and the magellan Medicaid Administration for pharmacy services number is 1-866-376-8255 I der must send at their expense legible copies of all Medicaid related information to the authorized state and federal agencies and their authorized representative upon the request of acha at the time of the request all records must be provided regardless of the media format on which their original records are retained by the provider fail you to make records available or to refuse access is a sanctionable offense for the first offense a $2,500 fine per record or instance of refused access and suspension until the records are made available or access is granted can be assessed to you as a provider when a provider is in violation of a Medicaid policy each day that an ongoing violation continues such as refusing to furnish Medicaid related records or refusing access records is considered to be a separate violation often they seek several remedies for violations of Medicaid policy there are some easily avoided yet common violations that providers can avoid and they include a provider who has failed to make available or refused access to Medicaid related records to an auditor investigator or other authorized employee or agent of akka the Attorney General a state attorney or the federal government poor a provider who is not furnished or has failed to make available such Medicaid related records as octa has found necessary to determine whether Medicaid payments are or were due and the amounts thereof keeping your Medicaid records in order and readily available is an important provider responsibility Florida statute section 409 point 9 1 3 as well as the Florida Administrative Code rule 59 G - nine point zero seven zero identify the sanctions that akka may impose for violations of Medicaid policy some of the sanctions include suspension from participation in the Medicaid program for up to one year termination from participation in the Medicaid program for twenty years or imposition of fines another helpful resource that the Florida Medicaid program has developed is the video named Medicaid provider compliance program and provider self audits please see the video at AHCA a Florida comm forward slash Medicaid /e - library the video provides a basic overview of federal and state requirements for health care providers to ensure program compliance it also provides general guidance for Florida Medicaid providers about common areas of non-compliance and how to avoid them additionally the video focuses on how a provider can increase compliance and conduct self audits now let's continue on to section 5 where we'll talk about additional Medicaid resources a great resource for providers is your area Medicaid program office the agency has 13 Medicaid area offices in 11 areas throughout the state the area offices serve as the local liaisons to providers and recipients the area offices help with provider relations and training Simar relations conducting site visits to providers and potential providers and handling exceptional claims processing you can find your area Medicaid program office by visiting the agency's website at my Medicaid - Florida comm there you will also find information publications provider training calendars and beneficiaries links another great resource is the Florida Medicaid provider training elibrary located on the web at AHCA my florida comm forward slash Medicaid /e - library the library contains training resources for Medicaid providers on Medicaid policy in the library you will find PowerPoint presentations and videos about policy and compliance the site allows you to choose a time that is convenient for you to review the training materials and allow you to learn at your own pace with self-paced learning materials you can build your knowledge of Medicaid policy decreasing the risk of non-compliance and avoiding billing errors did you know that the Florida Medicaid program has an email alert system the email alert system is used to supplement the present method of receiving provider alerts information and to notify registered providers or interested parties of late-breaking health care information an email will be delivered to your mailbox when Medicaid policy clarifications or other health care information is available that is appropriate for your selected provider type to subscribe to the automated alert system complete the online form at a HC ami Florida comm forward slash Medicaid and the Quick Links on the right there is a link to sign up for health care alerts once you are registered a confirmation email will be sent to your mailbox to avoid fraudulent subscription requests subscribers must return the confirmation email to complete their subscription in summary we would like to stress to providers the importance of following the compliance tips presented during this presentation make sure to thoroughly review your Medicaid provider agreement also refer to Medicaid policy as it is stated in the florida provider general handbook serve as specific coverage and limitations handbook and the Florida Medicaid provider reimbursement handbook use our website to look for updated policy manuals make sure you update and properly display required licenses for the goods or services you are providing also make sure to utilize the resources we've discussed the area offices the online elibrary training videos the email healthcare alerts and the agency Medicaid websites also keep in mind that if there is a change of ownership akhom must be notified prior to the change the requirements for notification are described in the florida medicaid provider general handbook records that relate to the sale or transfer of the business interest need to be maintained and readily available for inspection changes to your address or telephone numbers for individual providers and group providers need to be reported to the Medicaid fiscal agent as soon as they occur you can obtain the proper form from the website my Medicaid - florida.com as providers it is your role to ensure that member affiliations within a group practice are current and accurate providers are also required to notify the Medicaid fiscal agent currently HP Enterprise Services when associated practitioners leave the group both record-keeping and services need to be rendered in accordance with Medicaid policy familiarize yourself with a Medicaid provider handbook applicable for your practice and keep in mind that the policy may be different between Medicare and Medicaid providers also must ensure that member affiliations within a group practice are current and accurate and are required to notify the Medicaid fiscal agent when associated practitioners leave the group both record-keeping and services provided need to be rendered in accordance with Medicaid policy in conclusion of this training always remember that it is all of our responsibility to report suspected fraud abuse or overpayments to the Florida Medicaid program report any suspected Medicaid fraud to the Medicaid program integrity unit you can learn more about reporting fraud by watching the online video report Medicaid fraud thank you for joining us for this training on compliance tips for providers you