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Sample Customers

Blue Cross Blue Shield (31 organizations)
Centene Corporation
Cigna
Excellus
Health Care Service Corporation
Health Markets
HealthPartners
MBIA
Munich America Reinsurance
Midland National Life
North American Life
Palmetto GBA
Preferred Health Systems
The Travelers Companies

Insurance - CMS Medicaid MIC Audits

According to some estimates from CMS, the Medicaid Integrity Program, through the use of MIC audits, is expected to recover more overpaid revenues than the CMS RAC (Recovery Audit Contractor) program for Medicare. Without the proper tools, both providers and MCOs risk losing legitimate revenues through the MIC audits.

The MIC audit process is unique compared to other forms of CMS Audits such as MAC and RAC. The appeals process is managed at the State level and will vary from one state to the next. The appeals process may also vary depending on the organization type (healthcare provider, pharmacy, MCO, etc.) Also, unlike the Medicare RAC auditors, MIC auditors currently are not bound by limits on the number of claims records they can request in each audit. Because the scope of a MIC audit can be very large, and because of the complexities created by the varying processes from State to State, healthcare providers and managed care organizations will face many new challenges as they work to defend their legitimate revenues from recoupment.

MIC audits are conducted in distinct steps with each managed by a different type of MIC Audit Contractor:

Review MIC

The Review MICs are contracted to review actions of entities that provide Medicaid items or services. They are tasked with evaluating risks to the Medicaid programs, in terms of both financial risks and risks related to quality of care. They are also looking for indications of potential fraud, waste and abuse. Providers and MCOs will most often be selected for audits based on data analysis by the Review MICs. They also will be referred to the Audit MICs by State agencies. The Division of Fraud Research and Detection (DFRD) will utilize algorithms to help the Review MICs identify Medicaid providers whose billing activities indicate the potential for inaccurate payments. Providers and MCOs will be ranked in terms of risk, to help prioritize MIC audits.

Audit MIC

The Audit MICs are contracted to conduct claims audits based on the findings and recommendations of the Review MICs. Audit MICs have the authority to request copies of records, often via a letter. They also have the authority to request interviews with office personnel and have access to facilities. Requested records must be made available to the Audit MICs within the requested timeframes. Generally, providers and MCOs will have at least two weeks before the start of an audit to provide initial documents to the Audit MICs. A partial list of Medicaid Integrity Risks targeted by the MIC Auditors includes:

Providers

Provider eligibility
Billing for services not provided
Reimbursements for unapproved drugs
Duplicate billing
Providing services not medically necessary
Providing services that may compromise the quality of care
Excessive payments and “upcoding” for higher reimbursement of billed procedures
Billing for services provided by unlicensed or untrained personnel
Payments for unapproved transportation services
Medicaid eligibility in multiple states
Contingency fee payments to consultants and service providers
Excessive Medicaid administrative costs
Providing false certifications in the claims process

MCOs

Kickbacks between MCOs and providers
Paying for less care than is needed, in order to save money
Falsifying information during the contracting or enrollment processes
Misinformation in MCO marketing
Medicaid Eligibility in multiple states
Excessive Medicaid administrative costs
Embezzlement and theft
Providing false certifications in the claims process

The Audit MIC will generally share a draft of their audit findings with the State and then with the provider or MCO. The State and the provider or MCO will have an opportunity to review and comment on the initial findings. CMS will consider the comments and prepare a revised draft report. After a review with the State, CMS will finalize the audit report and specify any identified overpayments. Unlike other forms of CMS Claims audits, The State, not the auditor, will pursue the collection of any overpayments in accordance with State law. The appeal rights for providers and MCOs will vary depending on State law. The Audit MICs will be available to provide support and assistance to the States throughout the adjudication of the audit.

Education MIC

The Education MICs provide education on payment integrity and quality of care for Medicaid providers, MCOs and beneficiaries.

Using Compliance 360 to Manage MIC Audits

With Compliance 360, you can manage the entire MIC audit process, from the initial receipt of a request for records, through your State appeals process and adjudication. You can also establish efficient projects for managing proactive self-audits. Using random samples from your claims history, based on the high risk targets of the MIC Auditors, you can quickly assess your financial and legal risks. Armed with this information, you can make informed decisions regarding self-disclosure which often results in favorable treatment such as reduced or eliminated interest and penalties in many states.

With the Compliance 360 Claims Auditor for Managing MIC Audits, you can:

Take control of the MIC audit process to minimize the risk of losing your legitimate revenues.
Automate the management of the entire MIC audit process across all departments and create organizational accountability with highly configurable workflow. With automated workflow, the Claims Auditor functions as your “Virtual MIC Audit Coordinator”, enforcing deadlines and due dates throughout your organization and providing alerts that enable your team to avoid the automatic recoupment of legitimate revenues.
If your organization operates in multiple states, you will need a solution with the flexibility to manage appeals processes that will vary from state to state. Using the configurable workflow in the Compliance 360 Claims Auditor, you can establish unique workflows based on the audit and appeals process in each state while you centralize the management and monitoring of each audit.
Integrate MIC audits into your “Claims Audit System of Record”. Use the Compliance 360 Claims Auditor as your central location for managing MIC audits and all medical claims audits including RAC, MAC, CERT, PERM, MFCU, ZPIC and others. With the Compliance 360 Claims Auditor, there is NO ADDITIONAL COST, as you expand the use to incorporate all claims audits. There is no need to purchase or install additional software. The expansion is accomplished using configurable workflow capabilities and audit-specific workflow templates provided by Compliance 360.
Make well-informed decisions throughout MIC audit and appeals processes and proceed with appeals only when the outcome is likely to be successful.
Provide executive visibility with real-time dashboards. Executives and other key decision makers can closely monitor the status of pending MIC audit appeals and any other claims audit appeals to gauge the financial exposure of active medical claims audits.
Proactively establish barriers to MIC Auditors by demonstrating an “in control” status with efficient self assessments and internal defense audits.
Incorporate MIC audit management into your broader compliance and risk management programs using the comprehensive Compliance 360 GRC platform. This is important for hospitals and managed care organizations seeking to address the increasing governance and risk management needs of their boards of directors in today’s climate of increasing regulatory scrutiny and demands for oversight.
Accomplish all of these objectives without installing or maintaining any software or additional computers. The entire Compliance 360 system including the Claims Auditor is provided as a secure Internet service that can be accessed from any location.
Utilize complementary advisory consulting services to assess vulnerabilities and implement process improvements based on CMS guidelines. These services can also be used to assist with the defense of MIC audits and preparation for appeals.

The Compliance 360 Claims Auditor™ helps healthcare providers and MCO's manage a wide variety of medical claims audits and appeals, including MIC audits conducted under the CMS Medicaid Integrity Program (MIP). The Claims Auditor is part of the industry leading Compliance 360 solution for healthcare that enables a comprehensive approach to regulatory compliance and risk management through one comprehensive, enterprise-wide platform.

To request a personal demonstration of the Compliance 360 Claims Auditor, please Contact Us.

Free MIC Audit Training (On-Demand Webinars)

You are also invited to attend our live broadcasts or replay our on-demand recorded training webinars at your convenience. These training webinars have been attended by more than 10,000 participants and have received very positive feedback. Click Here for the full list of live and on-demand training webinars.

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To learn how leading insurance companies are using Compliance 360 to minimize their compliance overhead and risks, and how you can be doing the same, contact us today.