Author: Office of Compliance and Program Integrity
At various times of the year, Medicaid providers may receive notification of participation letters from the DMA Office of Compliance and Program Integrity (OCPI) which facilitates audits from various auditing agencies, e.g. Office of the Inspector General (OIG), Office of Internal Auditor (OIA), and Office of State Auditor (OSA).
As previously addressed in the August 2017 Medicaid Bulletin article, The Office of the State Auditor Single Audit:
- “NC Medicaid is authorized by Section 1902 (a) (27) of the Social Security Act and 42 CFR §431.107 to access patient records for purposes directly related to the administration of Medicaid, the Medicaid Waiver, and the NC Health Choice Program. In addition, when applying for Medicaid benefits, each recipient signs a release which authorizes access to his/her Medicaid records by NC Medicaid and other appropriate regulatory authorities. Therefore, it is not necessary for you to require a signed consent for the release of records from any affected Medicaid recipient to submit the necessary documentation for this review.”
If providers are notified that they are to submit service provision documentation for a Medicaid client, the submission process is extremely time sensitive. Timelines may vary slightly among audit agencies; but, usually the materials are due within 30 days upon the date of the notification letter, not the received by date. This time limit points to the importance of having updated contact information, especially the correct mailing address, in the NC Tracks portal.
At times, the auditing entity may request additional documentation about the case. When this occurs, the time limit for returning this information is often shorter than the time limit indicated in the initial request. Keep in mind that in many cases the audit process of reviewing documents is already underway. To minimize any delay, all documents related to the claim should be sent with the initial request.
Audit notification letters will include a list of specific items from within the specified Medicaid beneficiary’s file to send to the requesting agency. If providers have any doubt regarding the request, they should first contact the listed OCPI representative. Additionally, providers may call the Medicaid Contact Center in RTP. The local number is 919-813-5550, and the long-distance number is 1-888-245-0179. The call center staff will provide general facts and resolution of the information requested.
OCPI will make every effort to ensure the provider’s claims are reviewed fairly. However, if the additionally requested information is not submitted in a timely manner, there is an increased risk of the case being designated as an error. Not only will the State be held responsible for this designation and be required to implement corrective action plans with the providers; but, the provider will potentially be required to pay back all monetary gains that had been reimbursed related to the claim.
Office of Compliance and Program Integrity
DMA, 919-814-0000