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May 18, 2022, 12:00 EDT

Chapter 6: Utilization Review and Control (Pharm)

Updated: 12/16/2015

Under the provisions of federal regulations, the Medical Assistance Program must provide for continuing review and evaluation of the care and services paid through Medicaid, in­cluding review of utilization of the services by providers and by recipients.  These reviews are mandated by Title 42 Code of Federal Regulations, Parts 455 and 456.  The Department of Medical Assistance Services (DMAS) conducts periodic utilization reviews on all pro­grams.  In addition, DMAS conducts compliance reviews on providers that are found to provide services in excess of established norms, or by referrals and complaints from agen­cies or individuals. 

Participating Medicaid providers are responsible for ensuring that requirements for services rendered are met in order to receive payment from DMAS.  Under the Participation Agreement with DMAS, the provider also agrees to give access to records and facilities to Virginia Medical Assistance Program representatives, the Attorney General of Virginia or his authorized representatives, and authorized federal personnel upon reasonable request.  This chapter provides information on utilization review and control requirement procedures conducted by DMAS.

Financial Review and Verification

The purpose of financial review and verification of services is to ensure that the provider bills only for those services that have been provided in accordance with DMAS policy and that are covered under the Virginia Medical Assistance programs and services.  Any paid provider claim that cannot be verified at the time of review cannot be considered a valid claim for services provided, and is subject to retraction.

 

Compliance Reviews (Pharm)

DMAS routinely conducts compliance reviews to ensure that the services provided to Medicaid recipients are medically necessary and appro­priate and are provided by the appropriate provider.  These reviews are mandated by Title 42 C.F.R., Part 455.  Providers and recipients are identified for review by systems-gener­ated exception reporting using various sampling methodologies or by referrals and com­plaints from agencies or individuals.  Exception reports developed for providers compare an individual provider's billing activities with those of the provider peer group.  An excep­tion profile report is generated for each provider that exceeds the peer group averages by at least two standard deviations. 

To ensure a thorough and fair review, trained professionals employed by DMAS review all cases using available resources, including appropriate consultants, and make on-site re­views of medical records as necessary. 

Statistical sampling and extrapolation may be used in a review.   DMAS may use a random sample of paid claims for the audit period to calculate any excess payment.  When a statistical sample is used, the amount of invalid payments in the audit sample are com­pared to the total invalid payments for the same time period, and the total amount of the overpayment is estimated from this sample.  Overpayments may also be calculated based upon review of all claims submitted during a specified time period. 

Providers will be required to refund payments made by Medicaid if they are found to have billed Medicaid contrary to law or regulation, failed to maintain any record or adequate documentation to support their claims, or billed for medically unnecessary services.  In addition, due to the provision of poor quality services or of any of the above problems, Medicaid may restrict or terminate the provider's participation in the program.

Fraudulent Claims

Fraud means an intentional deception or misrepresentation made by a person with the knowledge that the deception could result in some unauthorized benefit to himself or some other person.  It includes any act that constitutes fraud under applicable federal or state law. 

Since payment of claims is made from both state and federal funds, submission of false or fraudulent claims, statements, or documents or the concealment of a material fact may be prosecuted as a felony in either federal or state court.  The Program maintains records for identifying situations in which there is a question of fraud and refers appropriate cases to the Office of the Attorney General for Virginia, the United States Attorney General, or the appropriate law enforcement agency.

Provider Fraud

The provider is responsible for reading and adhering to applicable state and federal regula­tions and to the requirements set forth in this manual.  The provider is also responsible for ensuring that all employees are likewise informed of these regulations and requirements.  The provider certifies by his or her signature or the signature of his or her authorized agent on each invoice that all information provided to DMAS is true, accurate, and complete.  Although claims may be prepared and submitted by an employee, providers will still be held responsible for ensuring their completeness and accuracy. 

Repeated billing irregularities or possible unethical billing practices by a provider should be reported to the following address, in writing, and with appropriate supportive evidence: 

Supervisor, Provider Review Unit

Program Integrity Section

Division of Cost Settlement and Audit

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219 

Investigations of allegations of provider fraud are the responsibility of the Medicaid Fraud Control Unit in the Office of the Attorney General for Virginia.  Provider records are avail­able to personnel from that unit for investigative purposes.  Referrals are to be made to: 

Director, Medicaid Fraud Control Unit

Office of the Attorney General

900 E. Main Street, 5th Floor

Richmond, Virginia 23219

Recipient Fraud

Allegations about fraud or abuse by recipients are investigated by the Recipient Audit Unit of the Department of Medical Assistance Services.  The unit focuses primarily on deter­mining whether individuals misrepresented material facts on the application for Medicaid benefits or failed to report changes that, if known, would have resulted in ineligibility.  The unit also investigates incidences of card sharing and prescription forgeries. 

If it is determined that benefits to which the individual was not entitled were approved, cor­rective action is taken by referring individuals for criminal prosecution, civil litigation, or establishing administrative overpayments and seeking recovery of misspent funds.  Under provisions of the Virginia State Plan for Medical Assistance, DMAS must sanction an in­dividual who is convicted of Medicaid fraud by a court.  That individual will be ineligible for Medicaid for a period of twelve months beginning with the month of fraud conviction. 

Referrals should be made to: 

Supervisor, Recipient Audit Unit

Program Integrity Section

Division of Cost Settlement and Audit

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219 

Referrals To the Client Medical Management (CMM) Program

DMAS providers may refer Medicaid patients suspected of inappropriate use or abuse of Medicaid services to the Recipient Monitoring Unit (RMU) of the Department of Medical Assistance Services.  Referred recipients will be reviewed by DMAS staff to determine if the utilization meets regulatory criteria for restriction to a primary physician or pharmacy in the Client Medical Management (CMM) Program.  See the "Exhibits" section at the end of Chapter I for detailed information on the CMM Program.  If CMM enrollment is not indicated, RMU staff may educate recipients on the appropriate use of medical services, particularly emergency room services. 

Referrals may be made by telephone, FAX, or in writing.  A toll-free HELPLINE is available for callers outside the Richmond area.  Voicemail receives after-hours referrals.  Written referrals should be mailed to: 

Supervisor, Recipient Monitoring Unit

Program Integrity Section

Division of Cost Settlement and Audit

Department of Medical Assistance Services

600 East Broad Street, Suite 1300

Richmond, Virginia 23219 

Telephone:  (804) 786-6548

CMM HELPLINE: 1-888-323-0589 

When making a referral, provide the name and Medicaid number of the recipient and a brief statement about the nature of the utilization problems.  Hospitals continue to have the option of using the "Non-Emergency Use of the Emergency Room" Referral Form when reporting emergency room abuse.  Copies of pertinent documentation, such as emergency room records, are helpful when making written referrals.  For a telephone referral, the provider should give his or her name and telephone number in case DMAS has questions regarding the referral.