​Medicaid Provider Self-Review Protocol

DHS  encourages providers to voluntarily come forward and disclose overpayments or improper payments of Medicaid (or Medical Assistance (MA)) funds. This protocol provides a mechanism to make these disclosures.

Providers are reminded that this is a voluntary protocol and does not affect the requirements of the Single Audit Act. Further, the protocol suggests that managed care organizations under contract with DHS educate their network providers about the self- review protocol and encourage the providers to use it.

We believe that this protocol will foster a  partnership between DHS and MA providers, thereby serving our common interest to protect the financial integrity of the MA Program. Providers have an ethical and legal duty to promptly return inappropriate payments that they have received from the MA Program. In order to encourage proactive efforts to identify and return inappropriate payments, DHS  will accept reimbursement for inappropriate payments without penalty in the event that such inappropriate payments are disclosed voluntarily and in good faith, and that the acts that led to the inappropriate payments were not the result of fraudulent conduct on the part of the provider, its employees, or agents.

It is an expectation  that this protocol will create an atmosphere that encourages voluntary compliance and self-disclosure by providers participating in the Pennsylvania Medical Assistance Program.


The Pennsylvania Medical Assistance Provider Self-Review Protocol

1. Introduction

The Department of Human Services (DHS) relies upon the health care industry to assist in the identification and resolution of matters that adversely affect the Medical Assistance (MA) Program, and believes that a cooperative effort in this area will serve our common interest of protecting the financial integrity of the MA Program and ensuring proper payments to providers. DHS encourages MA providers to implement necessary policies, processes, and procedures to ensure compliance with federal and state laws, regulations, and policies relating to the MA Program. As part of these policies and procedures, the DHS recommends that providers conduct periodic reviews to identify instances where services reimbursed by the MA Program are not in compliance with Program requirements.

DHS  established this  protocol for self-reviews by MA providers that participate in both the fee-for-service and managed care environments. While providers have a legal duty to promptly return inappropriate payments that they have received from the MA Program, the use of the protocol is voluntary. The protocol simply provides guidance to providers on the preferred methodology to return inappropriate payments to DHS. This voluntary protocol does not in any way affect the requirements of the Single Audit Act or other independent audit requirements.

DHS' Self-Review Protocol is intended to facilitate the resolution of matters that, in the provider's reasonable assessment, potentially violate state administrative law, regulation, or policy governing the MA Program, or matters exclusively involving overpayments or errors that do not suggest violations of law. It is possible that the Department may, upon review of information submitted by the provider or upon further investigation, determine that the matter implicates state criminal or federal law. In such instances, the Department will refer the matter to the appropriate federal or state agency.

When, either in the course of regular business or by using one of the options specified below, providers believe that they have been inappropriately paid, they should promptly contact the Bureau of Program Integrity (BPI) to expedite the return of the inappropriate payment. Providers benefit from self-reviews in several ways. By coming forward and identifying instances of possible noncompliance, the provider, rather than DHS, is conducting the review of his/her records. Further, and perhaps most importantly, when the provider properly identifies an inappropriate payment and reports it to DHS, and the acts underlying such conduct are not fraudulent, DHS will not seek double damages, but will accept repayment without penalty.

This protocol is equally applicable to managed care providers and fee-for-service providers. Inappropriate payments made by managed care organizations (MCOs) to providers within their networks inflate the costs of providing care to MA recipients, and DHS retains its right and responsibility to identify and recover payments or take any other action available under law. Providers should return any payments identified through this protocol directly to the MCOs if applicable but must also make the self-disclosure directly to DHS. We recommend that MCOs under contract with DHS educate their contracted providers on this protocol and encourage them to use it. Again, when a provider properly identifies an inappropriate payment and the acts underlying such conduct are not fraudulent, DHS will not seek double damages but will accept repayment without penalty.

2. Provider Options for Self-Reviews

Providers have several options for conducting the self-review and expediting the return of inappropriate payments to the Department:

Option 1: 100 Percent Claim Review — A provider may identify actual inappropriate payments by performing a 100 percent review of claims. This option is recommended in instances where a case-by-case review of claims is administratively feasible and cost-effective.

To the extent that payments can be returned through the claim adjustment process, the provider should follow the claim adjustment instructions in the applicable provider manual. Otherwise, providers should send refund checks made payable to the "Commonwealth of Pennsylvania" to the following address:

Department of Human Services
Office of Administration
Director, Bureau of Program Integrity
P.O. Box 2675
Harrisburg, PA 17105-2675

Providers who wish to submit refund checks by overnight delivery, please have mail directed to the Bureau's building address:

Department of Human Services
Office of Administration
Bureau of Program Integrity
Commonwealth Tower, 4th Floor
303 Walnut Street
Harrisburg, PA 17101

Refund checks should be accompanied by a cover letter that provides an overview of the issues identified, the time period covered by the review, including the reason for the time period selected, and the actions that have been or will be taken to assure that these errors do not reoccur in the future. Note that providers may be asked to work with DHS to ensure that we maintain correct paid claims information. Acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered.

Option 2: Provider-Developed Review Work Plan for BPI Approval — When it is not administratively feasible or cost-effective for the provider to conduct a 100 percent claim review, a provider may identify and project inappropriate payments pursuant to a detailed work plan submitted to DHS for approval. A provider that wishes to use this option should submit his/her proposal in writing to BPI at the above address.

The proposed work plan should also include an overview of the issues identified, the proposed time period of the review, including the reason for the time period selected, and the corrective action is taken to ensure that the errors do not reoccur in the future. BPI will, as it has in the past, review the submission and advise the provider accordingly.

Once the proposed plan has been approved by DHS, the review should be conducted, and inappropriate payment(s) projected. Providers should send refund checks to the address specified in Option 1. Again, acceptance of payment by the MA Program does not constitute agreement as to the amount of loss suffered.

3. Examples of Inappropriate Payments Suitable for Self-Reviews

Over the years, DHS' Bureau of Program Integrity has identified hundreds of situations involving inappropriate payments to MA providers. Many involve failing to maintain records in accordance with applicable regulations (55 Pa. Code §1101.51), performing or providing inappropriate or unnecessary services, or billing for services that were not rendered. A few of the more specific violations identified include the following:

  • A provider (e.g., pharmacy, medical supplier, laboratory, home health agency, EPSDT service provider) bills MA with an incorrect prescriber's license number. This, in effect, misrepresents the prescriber of the service.
  • A behavioral health rehabilitation services provider bills for more units of service, e.g. Therapeutic Staff Support (TSS), Behavioral Specialist Consultant (BSC), and/or Mobile Therapist (MT), than were prescribed in the Psychiatric/ Psychological evaluation for the client.
  • A behavioral health rehabilitation services provider discovers that an employee providing TSS, BSC, and/or MT services was not qualified to provide the services billed.
  • An inpatient hospital provider (provider type 11) includes outpatient services in the inpatient billings, resulting in an incorrect DRG payment.
  • A psychiatric inpatient hospital provider (provider type 01) bills and received payment for primary Drug and Alcohol services not payable to a psychiatric hospital or hospital psychiatric unit.
  • A hospital outpatient laboratory provider (provider type 01) bills both CPT Codes #87040 (aerobic and anaerobic) and #8076 (anaerobic) when CPT Code #87040 should have been the only code billed because it includes both the aerobic and anaerobic components.
  • Two or more physicians (provider type 31) involved in rendering an inpatient service bill different procedure codes for the same service.
  • A methadone maintenance provider (provider type 08, specialty 084) bills for services provided prior to the clinic supervisory physician's examination/evaluation and/or treatment plan.
  • A hospital outpatient radiology provider (provider type 01) bills individual diagnostic radiology codes separately for hand-wrist procedures when appropriate combination codes were available.
  • An inpatient physician provider bills Procedure Code 99233 without meeting at least two of the three required components.
  • A pharmacy provider (provider type 24) identifies claim adjustments that have not been made when the recipient(s) have not picked up their prescriptions.
  • An inpatient psychiatric and rehabilitation hospital or unit (provider type 01) bills and receives payments for more than two therapeutic leave days per calendar month.
  • An inpatient residential treatment facility (provider type 56) bills and receives full per diem reimbursement for days when residents were hospitalized at acute care facilities, private psychiatric hospitals, or psychiatric units (provider type 01). These days should be billed as hospital reserved bed days and paid one-third the facility's per diem rate up to the maximum fifteen days per calendar year.
  • A psychiatric partial hospitalization program (provider type 11, specialty 113 and 114) bills for time spent transporting the client to and/or from the partial program or for time spent in activities away from the licensed site.
  • A psychiatric outpatient clinic (provider type 08, specialty 110) bills for a medication administration visit when no medication was administered, or bills for services provided away from the licensed site (e.g. services provided in the schools).
  • A laboratory provider (provider type 28) bills for drug screens of clients at drug and alcohol clinics (provider type 08). Diagnostic laboratory services used to detect the clinic patient's use of drugs are included in the Drug and Alcohol clinic visit fee.
  • A hospice provider (provider type 06) incorrectly billed the Department without the required Certification of Terminal Illness.
  • An inpatient hospital provider (provider type 01) incorrectly uses ICD-9-CM V30 codes and receives improper DRG cost outlier payments.

4. Provider Inquiries

DHS recognizes that the application of this protocol to all of the various inappropriate payment situations may raise questions and concerns. DHS is determined, however, to make this process work and will work closely with providers to answer any questions that they may have.

Providers or their representatives that have questions regarding this protocol may contact the Department's Bureau of Program Integrity at (717) 772-1079 to discuss this protocol with the Provider Self-Review Protocol Coordinator.