I would like to propose the following addition to the below mentioned section.  

Issue: Provider education regarding audits.

Plan: At the conclusion of each year’s audits, DMAS will compile a list of common issues identified in those audits and share those with provider groups.  DMAS will also compile a list of common issues that were originally identified in the audits as being an issue but were later overturned in the reconciliation, informal appeal, and/or formal appeal.  This information will be used to ensure the Provider Manual provides the appropriate direction and explanation.   

The report, in general, summarizes the discussion and consensus of the workgroup.  I would make the following request for clarification of the "plan" for the issue "Provider participation in the audit process:"

• The first sentence references the auditors conducting an exit conference, this implies that the conference is conducted upon the end of their on-site work.
• The final sentence states that DMAS "follows-up" with an exit conference 30 days after the provider's receipt of the preliminary findings letter and their opportunity to provide additional documentation.  Is that conference conducted face-to-face?  Is it by the same "auditors" who conducted the original review and produced the preliminary letter?  Is it done prior to and to inform the final letter or is it simply a narration of the final letter.

The text, as written, is not clear and a frequent observation by providers reflects their frustration that even though additional documentation was provided in response to the preliminary findings, it is not acknowledged in the final letter.

DMAS staff are to be commended for their willingness to continue the dialogue.

Thank you for the opportunity to provide the following comments:

Issue: Provider audits are too lengthy causing hardships in record retrieval

Recommendation:  Set time limit on the time the auditor conducts their review. Auditors should have a set time period to complete the audit: from the moment the auditor walk’s into a provider’s office to begin the audit until the preliminary finding are sent to the provider.

Although my recommendation does not perfectly intent of the topic, the time period providers must adhere to creates hardships. Providers must review the same documents the auditors reviewed during the audit, however providers are given a controlled time schedule to review and respond, while auditors review untethered.

Issue: Provider education regarding the audit process

Provider groups? – Does this mean that the information will only be submitted to “provider representative organizations?” I ask this question because I was informed on another occasion by a DMAS representative that "DMAS would not send information to all providers. The information would be dispersed via provider representative organizations.” If this is the case, how will providers that do not subscribe to a representative organization gain timely access to the information

Recommendation: ALL information pertinent to Providers should be dispersed through Medicaid Memo and placed on DMAS website.

“DMAS will share areas of audit emphasis with provider groups prior to beginning that years audit and clarify how auditors plan to evaluate compliance with the requirements set forth in regulations and the provider manual.” Great…

Recommendation: Providers should have access to a audit customer service section. The audit customer service line must have someone that is thoroughly trained to understand the audit compliance evaluation process and the related interpretation of regulations. This cannot be the general customer service line.

“These provider groups will be given the opportunity to provide feedback to DMAS regarding proposed audit point of focus”

Recommendation: Notice of the opportunity to provide feedback should be dispersed to ALL providers via Medicaid memo.

Issue: Provider participation in the audit process

1. “Auditors will conduct a detailed exit conference prior to issuance of the final report.” – Is this the informal hearing? Please clarify what this looks like in the process. Is this a phone call, a face-to-face meeting, a letter in the mail, an email?
2. ‘The provider has 30 calendar days from receipt of the preliminary findings to request a re-review and provide additional documentation to the Agency.” Got it but 3 is confusing…
3. “After 30 days DMAS follows up with an exit conference to discuss with the provider the final findings and the next steps in the process”

 a) this seems similar to 1 is it the same?

b) does this mean 30 days after 2?

c) 30 calendar days or work days?

d) when does the 30 day count begin?

Issue: Provider education regarding audits

Recommendation: 1) Disperse information via Medicaid memo and put on DMAS website. 2) Create a Audit customer service line staffed with person's thoroughly trained in the audit process and applicable interpretation of regulations

Issue: DMAS documentation requirements are unclear to members in the provider community

“…DMAS posts its Provider manuals on its website for public comment for 30 days prior to making any amendments to the manuals. DMAS encourages providers to comment on any areas of the manuals that need clarification.” - The DMAS response dismisses the essence of the issue.

This is often the root issue of the audit concerns of providers. I would take a chance to say that every manual on the DMAS website falls short of clarity. How many manuals are open for public comment at this time? The response provided by DMAS seems to divert responsibility to the providers when in actually there is no active process in place to accomplish what DMAS suggested.

Recommendation:

1. DMAS should begin a process of review of all manuals (Notice sent to all providers via Medicaid Memo)
2. DMAS should revamp Provider hotline. Instead of a general provider helpline a provider is connected with specific manual customer service representative section. (If I have a question about Respite Care on the EDCD Waiver I am transferred to a customer service agent that is thoroughly trained in the EDCD regulation.
3. DMAS should review the qualifications and training for its agents on the Provider Helpline
4. DMAS must take a proactive approach to ensuring provides have access to the resources, training and support necessary to meet the DMAS standard.
5. If providers are failing to meet the DMAS standard, DMAS should take an inward look to seek a solution to the issue.

"The single biggest problem in communication is the illusion that it has taken place." - George Bernard Shaw

Issue: The Workgroup has not come to a consensus on the issue of material breach or substandard compliance standard.

Recommendation:

1. Workgroup
2. A process of consideration for audit instances that may fall under the umbrella of material breach while the workgroup is formulating and finalizing a statement of agreement and plan of action.

The Virginia Bar Association (VBA) appreciates the opportunity to comment.  The VBA has prepared proposed edits to the draft report and will email that Word document to Susie Puglisi at DMAS.

The VBA would also request that the presentations given by DMAS at the workgroup meetings also be inlcuded as an attachment to the final report that is provided to the General Assembly.