Florida Payment Error Rate Measurement (PERM)
Provider Alerts

January 9, 2018

Payment Error Rate Measurement Information for Medicaid & CHIP Providers Regarding Medical Record Request Notification if Sampled

The Payment Error Rate Measurement (PERM) program measures improper payments in Medicaid and Children’s Health Insurance Program (CHIP) and produces error rates for each program.  The Centers for Medicare and Medicaid Services (CMS) developed this program to comply with the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) and related guidance issued by the Office of Management and Budget.

The PERM error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the federal fiscal year (FFY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.  FFY 2008 was the first year in which CMS reported error rates for each component of the PERM program.

CNI Advantage, LLC, the federal review contactor (RC) under PERM, has begun reaching out to Medicaid and CHIP providers whose claims have been selected for review in a sample measurement conducted under the 2017 (October 1, 2016-September 30, 2017) PERM project.  If a claim from your office has been selected for review, you will be receiving a call from a CNI Advantage, LLC representative to verify the appropriate contact and address to mail and/or fax the medical records request pertaining to the sampled claim.  Once this information is verified, the medical records request will be sent to that contact person requesting all medical records pertaining to the sampled claim.

Records must be submitted to CNI Advantage, LLC within seventy-five (75) calendar days from the date you are contacted.  Follow-up contact regarding these medical record requests may be made by Florida Medicaid staff if any request is nearing the 75 day time limit.

If requested supporting medical documentation is not submitted, the claim will be coded as an error and any monies paid will be recouped.  Since dollars estimated as being paid in error are projected to all claims, the actual impact of each claim error will be magnified several times, resulting in an overall and exponentially negative impact on the Florida Medicaid program.  If the error rate is excessive, the Agency for Health Care Administration may be required to add controls or other limitations to address problem areas that are identified. It must be emphasized that even small dollar claim amounts identified as payment errors can have a significant impact on how a particular service area is perceived.  As such, it is important that providers submit requested medical records in a timely manner.

Please note that providers are required by Section 1902(a)(27) of the Social Security Act to retain records necessary to disclose the extent of services provided to individuals receiving assistance and furnish CMS, and its contractors,  with information regarding any payments claimed by the provider for rendering services.  Furnishing information includes submitting medical records for review.

The collection and review of protected health information contained in individual-level medical records for payment review purposes is permissible by the Health Information Portability and Accountability Act of 1996 and stated in 45 Code of Federal Regulations, parts 160 and 164.

If you would like to see a sample of the medical records request letter or you would like more information related to PERM and your role in this process, please visit the CMS PERM website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers.html.

Please look for additional details as they become available from the PERM RC in upcoming Provider Alerts and on the Agency’s website (http://ahca.myflorida.com/Medicaid/perm/).

For PERM related inquiries, you can contact us at FL_PERM@ahca.myflorida.com.

We appreciate your continued cooperation with the Florida Medicaid program.

10/11/2017

Payment Error Rate Measurement Information for Medicaid & Children's Health Insurance Program Providers Regarding Medical Record Requests

The Payment Error Rate Measurement (PERM) program measures improper payments in the Medicaid and Children’s Health Insurance Program (CHIP) and produces error rates for each program.  The Centers for Medicare and Medicaid Services (CMS) developed this program to comply with the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) and related guidance issued by the Office of Management and Budget.

The PERM error rates are based on reviews of fee-for-service (FFS), managed care, and eligibility components of Medicaid and CHIP in the federal fiscal year (FFY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.  FFY 2008 was the first year in which CMS reported error rates for each component of the PERM program.
Beginning in late calendar year 2017, CNI Advantage, LLC, the federal review contactor (RC) under PERM, will be reaching out to Medicaid and CHIP providers whose claims have been selected for review in a sample measurement conducted under the 2017 PERM project.  If a claim from your office has been selected for review, you will be receiving a call from a CNI Advantage, LLC representative to verify the appropriate contact and address to mail and/or fax the medical records request pertaining to the sampled claim.  Once this information is verified, the medical records request will be sent to that contact person requesting all medical records pertaining to the sampled claim. 

Records must be submitted to CNI Advantage, LLC within seventy-five (75) calendar days from the date you are contacted.  Follow-up contact regarding these medical record requests may be made by Florida Medicaid staff if any request is nearing the 75 day time limit.   

If the requested supporting medical documentation is not submitted, the claim will be coded as an error and any monies paid will be recouped.  Since dollars estimated as being paid in error are projected to all claims, the actual impact of each claim error will be magnified several times, resulting in an overall and exponentially negative impact on the Florida Medicaid program.  If the error rate is excessive, the Agency may be required to add controls or other limitations to address problem areas that are identified. It must be emphasized that even small dollar claim amounts identified as payment errors can have a significant impact on how a particular service area is perceived.  As such, it is important that providers submit requested medical records in a timely manner. 

Please note that providers are required by Section 1902(a)(27) of the Social Security Act to retain records necessary to disclose the extent of services provided to individuals receiving assistance and furnish CMS, and its contractors, with information regarding any payments claimed by the provider for rendering services.  Furnishing information includes submitting medical records for review. 
The collection and review of protected health information contained in individual-level medical records for payment review purposes is permissible by the Health Information Portability and Accountability Act of 1996 (HIPAA) and stated in 45 Code of Federal Regulations, parts 160 and 164.

If you would like to see a sample of the medical records request letter or you need more information related to PERM and your role in this process, please visit the CMS PERM website at https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicaid-and-CHIP-Compliance/PERM/Providers.html.

Please look for additional details as they become available from the PERM RC in upcoming Provider Alerts and on the Agency’s website (http://ahca.myflorida.com/Medicaid/perm/).

For PERM related inquiries, you can contact us at FL_PERM@ahca.myflorida.com.

We appreciate your continued cooperation with the Florida Medicaid program.

4/26/2017

Payment Error Rate Measurement (PERM) Webinar Training for Medicaid and CHIP Providers

Tuesday, May 9, 2017, 10:00 – 11:00 am
and
Thursday, May 11, 2017,   2:00 – 3:00 pm

The Payment Error Rate Measurement (PERM) program measures improper payments in Medicaid and CHIP and produces error rates for each program.  The Centers for Medicare and Medicaid Services developed this program to comply with the Improper Payments Information Act (IPIA) of 2002 (amended in 2010 by the Improper Payments Elimination and Recovery Act or IPERA) and related guidance issued by the Office of Management and Budget.

The PERM error rates are based on reviews of the fee-for-service (FFS), managed care, and eligibility components of Medicaid and Children’s Health Insurance Program (CHIP) in the federal fiscal year (FFY) under review. It is important to note the error rate is not a “fraud rate” but simply a measurement of payments made that did not meet statutory, regulatory or administrative requirements.  FFY 2008 was the first year in which CMS reported error rates for each component of the PERM program.

The webinar training will provide an overview the PERM program.  Focus topics will include sharing Florida’s Medicaid medical record review findings from FFY 2014 and preparing Florida Medicaid and CHIP Providers for the upcoming medical records requests during FFY 2017.   Please click the below link to register for one of the training dates.

Register now!

May 9th https://attendee.gotowebinar.com/register/4672952287791747329
May11th https://attendee.gotowebinar.com/register/908956749030903041

7/29/2016

Medicaid Provider Reminder

The Agency for Health Care Administration (the Agency) reminds all providers receiving reimbursement through the Medicaid fee-for-service delivery system that they must comply with all requirements in general and service-specific Florida Medicaid handbooks and policies.

Providers must report address changes and any change in their managing employees in accordance with their Medicaid Provider Agreement and the Florida Medicaid Provider General Handbook to ensure accurate communication and prompt payment for services rendered.

If you have changed your address or telephone number and have not updated your information with the Agency, this is a good opportunity to do so.  The Provider General Handbook (page 2-49) requires the following:

“Providers must promptly notify Medicaid of any change of address by calling the Medicaid fiscal agent’s Provider Services Contact Center at 1-800-289-7799 and selecting Option 4.  The following four addresses may be housed on the provider file: service address, pay-to-address, mail-to or correspondence address, and home or corporate office address.”

If closing out a former managing employee, list the individual’s name and the date they departed.  If adding a new managing employee, list the individual’s name, home address, date of birth, social security number, whether they are the financial or medical custodian, and the date they started.  Background screening is required.  Please view the Background Screening page under Enrollment on the Medicaid Public Web Portal for more information.

Florida Medicaid coverage policies are located on the Agency’s Florida Medicaid Web Portal.

To receive notifications on specific Florida Administrative Code (FAC) Agency rules, visit the FAC Web site and select “Subscribe for Notifications.”  Updates on Florida Medicaid rules are also posted to the Agency’s Rules Web site.

3/4/2016

Medicaid Compliance Awareness

Providers are encouraged to develop a compliance-training program, to seek educational opportunities, and to educate staff on the statutes, rules, contracts, and federal and state regulations that govern the Florida Medicaid program.

The Medicaid Provider Agreement states that a provider agrees to comply with all local, state, and federal laws, as well as rules, regulations, and statements of policy applicable to the Medicaid program.

Sources of Florida Medicaid policies include, but are not limited to, provisions of Chapter 409, Florida Statutes, Rule 59G, Florida Administrative Code, and Medicaid Handbooks.

The Office of Medicaid Program Integrity conducts reviews for provider non-compliance and oversees the activities of providers to ensure that fraudulent, abusive behavior and neglect of recipients occur to the minimum extent possible.  Florida Statutes and rules allow the Agency to pursue overpayments; to impose sanctions such as fines, suspensions, terminations; and to assess costs pertaining to investigative, legal, and expert witness expenses.  For example, goods or services when provided must be medically necessary and must be properly documented when rendered.  In regard to record retention, Section 409.913(9), Florida Statutes, states, “A Medicaid provider shall retain medical, professional, financial, and business records pertaining to services and goods furnished to a Medicaid recipient and billed to Medicaid for a period of five years after the date of furnishing such services or goods.” Failure of a provider to meet medically necessary requirements, failure to maintain required documentation, or failure to furnish documentation to the Agency are some examples of Medicaid policy violations that can result in overpayments due back to the Agency by the provider, as well as sanctions being imposed and costs assessed for recovery of expenses.

You are encouraged to enhance your knowledge of Medicaid policy to avoid billing errors and non-compliance issues.

10/7/2014

Requirements to Notify the Department of Children and Families (DCF) of Nursing Facility Admissions and Discharges

The Florida Department of Children and Families (DCF) must be notified of a Medicaid recipient’s admission to a nursing facility or discharge from a nursing facility, including those recipients enrolled in the Statewide Medicaid Managed Care (SMMC) Long-term Care (LTC) program and in the SMMC Managed Medical Assistance (MMA) program.  Upon notification of a nursing facility admission or discharge, DCF updates the recipient’s demographic information in the DCF computer system and makes any necessary changes in the recipient’s Medicaid eligibility aid category and patient responsibility. 

Within 10 working days of the Medicaid recipient’s admission to a nursing facility, DCF must receive a completed DCF #2506A Form (Client Referral/Change).  When the recipient is not enrolled in the LTC program, the nursing facility must submit the DCF #2506A Form to DCF.  When the recipient is enrolled in the LTC program, the case manager with the LTC plan must submit the DCF #2506A Form to DCF.  If a LTC plan delegates submission of the DCF #2506A Form to the nursing facility, the LTC plan must obtain a copy of the form submitted to DCF and retain a copy of that form in the plan member’s (enrollee’s) file.

Within 10 working days of the Medicaid recipient’s discharge from a nursing facility, DCF must receive a completed DCF #2506 Form (Client Discharge/Change Notice) from the nursing facility when the recipient is not enrolled in the LTC program and a completed DCF #2515 Form (Certification of Enrollment Status, Home and Community Based Services (HCBS)) from the LTC plan when the recipient is enrolled in the LTC program.  LTC plans may not delegate submission of the DCF #2515 Form to the nursing facility. 

The DCF #2506 Form, DCF #2506A Form, the DCF #2515 Form, and the instructions for the DCF #2506A and #2515 are accessible the Medicaid Nursing Facility Provider Information website.