Date: May 7, 2020
To: Participating Medical Assistance Program Providers
Re: Payment Error Rate Measurement (PERM) Audit for Reporting Year 2019
To comply with the Improper Payments Information Act of 2002, the federal Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS) has implemented a Payment Error Rate Measurement (PERM) program, which measures improper payments within each state's Medicaid program and Children's Health Insurance Program (CHIP). Each state is required to participate in PERM every three (3) years.
This notice serves as a reminder that all services for which charges are made to the Illinois Department of Healthcare and Family Services (the Department) are subject to audit. Audits are an important and necessary part of the Department's monitoring of health care facilities and services, as required by federal and State law. Audit findings against a provider will result in the recovery of resulting overpayments. Audit findings against a provider may also result in sanctions or other penalties, including but not limited to: (1) termination or suspension of the provider's eligibility to participate as a Medicaid and/or CHIP provider; (2) suspension or denial of the provider's payments; and (3) civil monetary penalties.
Reporting Year 2019 PERM Review
The PERM audit for reporting year (RY) 2019 (July 2, 2017 – June 30, 2018) was conducted by the federal government and resulted in the following errors being cited:
- Provider responded that the records could not be located.
- Provider did not have the participant on file or in the system.
- Provider stated that the participant was not seen on the sampled date of service.
- Provider submitted a record for the wrong date of service.
- One or more documents were missing from the record that is required to support the payment.
- Provider did not submit a record with daily documentation of specific tasks to support the payment.
- Provider was unable to retrieve the signature log.
- Provider did not submit required progress notes applicable to the sampled date of service.
- Provider did not submit the service plan.
- Provider did not have documentation that the claim was reversed.
- Date of service is incorrect, but within 7 days of the date of service billed on the claim.
Ø Corrective Action to Address the Missing, Incomplete, and Inadequate Documentation Errors: Providers are to follow the policy and procedures issued in the general handbook for all providers, Chapter 100 – General Policy and Procedures, Topic 110 - Record Requirements, subtopics 110.1 to 110.3 - Maintenance, Retention and Availability of Records.
National Provider Identifier (NPI) Missing on Claim
- Attending provider NPI required, but not submitted on institutional claim.
- Attending provider not enrolled.
- Ordering/referring/prescribing (ORP) provider NPI not listed on claim.
- ORP provider not enrolled.
Ø Corrective Action Regarding Attending NPI Requirements: Hospital, hospice, ambulatory surgical treatment centers, and renal dialysis clinics should refer to the informational notice dated November 1, 2019. Effective January 1, 2020, services that require an attending provider NPI will be edited to ensure the attending NPI is an individual and is enrolled.
Ø Corrective Action Regarding Ordering/Referring/Prescribing (ORP) Provider NPI Requirements: 42 CFR 455.440 requires that all claims for services that were ordered or referred contain the NPI of the physician or other professional who ordered or referred such services. 42 CFR 455.410 further requires that those ordering or referring physicians or other professionals be enrolled as participating providers.
Providers should refer to the informational notice dated December 19, 2019. Effective January 1, 2020, services that require an order or referral must have an individual practitioner’s NPI included on the claim, or the claim will be rejected. ORP providers are required to enroll in IMPACT. The ORP provider must be an individual and cannot be an entity.
Additional information related to NPI requirements can be found in Chapter 100 – General Policy and Procedures, Topic 101 - Provider Enrollment, subtopics 101.1 - Illinois Medicaid Program Advanced Cloud Technology (IMPACT) and 101.2 - Prerequisite Enrollment Steps for Providers.
By informational notice dated September 23, 2019, providers were notified of a provider directory that may be accessed to verify enrolled providers for dates of service that require providers be enrolled. The provider directory is linked from the IMPACT homepage.
Interim Medicaid Administrator