As reported in the May 2015 PDT, based on a significant challenge posed by a Medicaid Recovery Audit Contractor (RAC) in Nebraska that impacted all Medicaid participating dentists in the state , the Nebraska Society of Pediatric Dentistry and the Nebraska Dental Association (NDA) pursued RAC Audit reform legislation. Legislative bill 315 was introduced, followed by a legislative hearing. During the February 18, 2015 hearing on this bill, both pediatric and general dentists testified including pediatric dentists Drs. Jessica Meeske and Dr. Eric Hodges. Also testifying were medical, hospital, community health center, nursing home, and pharmacy associations. Ron Wiseman, the office manager of pediatric dentist Dr. Lourdes Secola-Ocanto, also provided heartfelt testimony.
While Medicaid RAC audits are required under the Affordable Care Act, the implementing federal regulations do not provide a precise framework for how such audits are conducted. LB 315 is an effort to resolve that, and is being considered a model for legislation in other states. Approved by the state legislature and signed into law by Nebraska Governor Pete Ricketts on May 29, 2015, LB 315 requires the following of RAC auditors utilized by the state’s Medicaid program:
- They may only reviews claims within two years of the date of payment.
- They must send a determination letter within 60 days of a provider submitting all requested material.
- They must utilize a licensed health care provider from the area of practice being audited to establish relevant audit methodology consistent with practice guidelines, standards of care, and state-issued Medicaid provider handbooks.
- They must provide greater due process for notification of an adverse determination and scheduling of onsite audits, along with the right to appeal a determination. This includes an informal appeals process along with a formal administrative appeal. A provider must receive advance notice of not less than 10 business days for an on-site audit, and the auditor must make a good faith effort to establish a mutually agreed upon time and date.
- They must exclude from medical necessity reviews cases in which the provider had obtained prior authorization for the service and service was performed as authorized.
- They may audit no more than five percent of the number of claims filed by the provider being audited, not to exceed 200 records. A provider must have at least 45 days to respond to and comply with a records request.
- They must submit an annual report, posted on the state’s DHHS website, regarding their performance, including the amount of overpayments and underpayments identified.
- Along with the state DHHS, they must perform annual education and training programs for providers, including description of common issues, problems and mistakes identified through audits and reviews along with opportunities for improvement.
- They are prohibited from recovering overpayments until all informal and formal appeals have been completed, except in cases where this is a credible allegation of fraudulent activity by the provider.
- For any contingent fee contract, they must be paid the same for overpayments or underpayments.
- They must allow electronic submission of requested records.
Special thanks goes to:
- Dr. Jessica Meeske, AAPD Council on Government Affairs NorthCentral district representative. She is pictured in the photo with the governor.
- Dr. Holly Portwood, Nebraska Academy of Pediatric Dentistry Public Policy Advocate.
- Dr. Scott Morrison, Nebraska Dental Association president.
- Kim Robak, Esq., Nebraska Dental Association contract lobbyist.
- David O’Doherty, Nebraska Dental Association executive director.
For further information please contact Chief Operating Officer and General Counsel C. Scott Litch at (312) 337-2169 or firstname.lastname@example.org.