About our Audits
MPRO, under contract with the Department of Community Health, Office of Health Services Inspector General (OHSIG) has been given the responsibility to assist in auditing fee-for-service payments made to hospitals for inpatient and outpatient services paid under Title XIX of the Social Security Act.
The OHSIG was established in October of 2010 as an independent, autonomous entity within the Michigan Department of Community Health (DCH) through Executive Order 2010-1. The Executive Order tasked the OHSIG to “… conduct and supervise activities to prevent, detect and investigate fraud, waste and abuse in Health Services Programs.” This includes the power to collect overpayments, restitution amounts and settlement proceeds inappropriately paid through health services programs including Medicaid.
Our payment reviews focus on areas that are problematic, i.e., medical necessity of services, coding errors, duplicate claims and pricing errors.
DRG validation audits ensure the coded and reported diagnoses and procedures accurately reflect the attending physician description and the information contained in the medical record.
Hospital inpatient and outpatient audits authenticate coding, supporting documentation, proper setting and Medicaid billing requirements.
MPRO’s methodology for these audits will be the use of Automated and Medical Records Reviews. The Automated Review process will involve MPRO analyzing the Medicaid Claims data for improper payments such as: duplicate claims, coverage or coding errors, pricing mistakes, etc. The Medical Records Reviews will consist of MPRO making a request for medical records and then doing a comparison of the submitted claims against the medical records maintained by the audited provider. All Medical Records Reviews will be undertaken by appropriate professional staff with expertise in the field of medicine being reviewed (such as registered nurses, therapists or other relevant health care professionals). All coding determinations will be made by certified coders with specialized knowledge of State and Federal Medicaid regulations and policy.
Audited providers will be notified of the findings of these audits and providers that disagree with the findings will have an opportunity to appeal. All appeals will be handled according to the MI Administrative Code, Sections R400.3401 – R400.3424. For all options related to MDCH appeals: http://www7.dleg.state.mi.us/orr/Files/AdminCode/106_01_AdminCode.pdf
Providers will be notified by mail if they are being audited by MPRO. The notification will consist of an introductory letter and will include the case selection that MPRO will review. The letters will be mailed to the address listed in the CHAMPS Provider Correspondence Address and will be addressed to ‘Medical Records – Medicaid Liaison’ with copy to the CEO. It is important that providers be aware that there is a 30 day response time frame from the date of the letters sent. It is also important that the providers ensure that the staff responsible for handling the mail at this address is aware that they should handle this audit correspondence in a timely manner to ensure providers will have sufficient time to gather documents and respond to the request.
If you have any questions, please contact Toria Spencer at 248-465-7368.