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Medicaid Audit

Medicaid audits are driven by the overall goal of identifying overpayments, and ultimately, decreasing the payment of inappropriate Medicaid claims. Medicaid Integrity Contractors ensure that Medicaid payments have been made for covered services that were actually provided, properly billed, and documented. The Medicaid RAC program was established in 2010, based on the success of the Medicare RAC program. Individual states are required to commission one or more RAC contractors to identify overpayments and underpayments made by the state Medicaid agency, and to recoup overpayments. In response to significant uncontrolled fraud and abuse, some state Medicaid agencies have set up separate OMIG (Office of the Medicaid Inspector General) units to enhance identification and recovery efforts.

Given the complex process for appeals and stringent penalty clauses, health plan providers should prepare themselves to handle the entire Medicaid audit process from a position of strength and confidence.

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MetricStream Medicaid Audit Software Solution

MetricStream offers comprehensive solutions that not only automate, streamline, and integrate the preparation for Medicaid audits, but also promote a more proactive approach to the process. From fulfilling record requests, to ensuring timely submissions, to making determinations and appeals, the solution enables organizations to manage all aspects of Medicaid audit requirements on a single, centralized platform.

With the MetricStream solution, health plan providers are well able to manage the different steps of creating, compiling and reviewing claims, collaborating with different stakeholders, and managing appeals in a smooth and efficient manner. The automatic routing of information to various stakeholders such as the Revenue Recovery department and the Appeals Coordinator is made possible with the help of the solution's in-built workflows. The entire appeals process is simplified by automating the task of preparing, reviewing, approving and finalizing appeals.

Advanced capabilities such as built-in status tracking and reporting, integrated document management, remediation action workflows and auto generation of letters allow organizations to implement industry best practices for regular self-assessments and internal audits. The solution empowers organizations to stay ahead of Medicaid audit requirements, while mitigating the risk of losing legitimate earnings.

Centralized dashboards enhance visibility into the process, enabling managers to easily track the Medicaid audit status. Powerful reporting capabilities provide trends and graphical charts based on a wide range of variables, including the service that is being audited, the physician associated with the service, and diagnosis codes. By tracking the audit patterns thus, the solution enables health plan providers to gain a complete view of the appeals at every stage.

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