Volume 15, Issue 3
Surveillance and Utilization Review Expansion
Over the past several months, the Department of Health and Hospitals Medicaid Program has undergone many changes that directly impact the Medicaid provider community. As you know, these initiatives include the new Medicaid Plastic Identification Cards, the introduction of Managed Care, and an upgraded Automated Recipient Eligibility Verification System (REVS). In addition to these initiatives, the Department of Health and Hospitals Office of Program Integrity, in partnership with Unisys, has expanded the Program�s Surveillance and Utilization Review (SUR) function.
Historically, this function has been used to review providers after Medicaid claims have been paid, using a combination of computer runs and skilled Medicaid staff as the part of the reviewing process. This process has been used to curb Medicaid fraud and abuse, protecting Medicaid providers and the state of Louisiana from the detrimental effects of rising costs that are associated with abuses of the Medicaid
Beginning July 1, 1998, the State�s SUR review capability will be greatly expanded and enhanced, able to survey and review more providers than ever before. The medical staff reviewing cases will be increased, and a new, personal computer-based SUR system will provide powerful, innovative technology to fight fraud and abuse. This new technology will allow DHH and Unisys to monitor many cases. Under this expansion, each participating Medicaid provider should anticipate an audit during his/her association with the Louisiana Medicaid Program. According to David Hood, Secretary of DHH, this larger review continues the Department�s efforts to rid the Medicaid Program of fraud and abuse.
�Past efforts to combat abuses of the Medicaid Program have shown us that the majority of our providers are honest,� Secretary Hood said. �But, we are increasing our surveillance of all providers in order to identify those who abuse the system. This is our commitment to the taxpayers of Louisiana.�As always, we thank the Medicaid provider community for its support and continued participation in the Louisiana Medicaid Program.
Notice to Obstetricians & Pediatricians
Question: Can a Medicaid-enrolled obstetrician require, as a condition of delivery, that his/her pregnant Medicaid recipient select, by her seventh month of pregnancy, a pediatrician to attend the expected baby�s
Answer: We were recently informed by the HCFA regional office in Dallas that Title XIX statutory and regulatory requirements do not prohibit obstetricians from engaging in this practice.Regulations do, however, prohibit the pediatrician from charging the pregnant recipient a retainer fee for the service to be rendered if the pediatrician plans to later accept the recipient�s Medicaid card for services rendered. No retainer fee may be charged.
Waiver Provider Reminder
Effective with date of service 4/1/97, the following codes should be used when billing for the Elderly and Disabled Adult
Z0070 - PCA Service, 1/2 hour units reimbursement $5.00 per
Z0071 - Household Support, 1/2 hour units $4.00 per unit
Z0072 - Personal Supervision, 1/2 hour units $3.00 per unit
Z0073 - Personal Supervision Night, 1/2 hour units, $2.00 per unit
Notice to Physicians and KIDMED Clinics
Code J6035, Immunization, Comvax, (Hep B/HIB) was placed in a non-pay status effective June 1, 1998. The new CPT code, 90748, will now be used to bill for the administration of the combination Hepatitis B/HIB vaccine and will be payable at the rate of $9.45. The Hepatitis B/HIB vaccine is available through the Vaccines for Children Program.
Providers are reminded to use CPT code 78990 when billing for the provision of diagnostic radionuclide(s). These claims should be billed on paper with a copy of the invoice indicating the cost of the radionuclide attached.Procedure code A4641 should be used only for crossover Medicare/Medicaid claims.
Depression in the Elderly
Lance Nickelson, Pharm.D., David Matthews, Pharm.D.,
Edwin Adams, Pharm.D
ISSUES . . .
--The incidence and risks of depression in the elderly
--The risk factors for depression in the elderly, some of which are specific to elderly
--Diagnosis, guidelines and considerations of treating depression in elderly patients.
This article will provide a brief overview of the incidence and risks of depression, the diagnosis, and guidelines and considerations for treatment of depression in older patients.
Depression can profoundly impair a person�s cognitive function, regardless of age. Patients with depression have substantially lower social functioning than those with hypertension, diabetes mellitus, arthritis, angina, or coronary artery disease. Geriatric patients and health providers sometimes accept this incapacitation as a natural consequence of aging rather than as symptoms of depression. Mortality from suicide and other causes is greater in elderly patients with depression than in people of a similar age without depression. The suicide rate in elderly persons is higher than that in the general population.
Depression is a serious health problem for the United States, especially when one couples the �graying� of the Baby Boomers with the general population trend toward living longer. In terms of impact on the health care system, the oldest-old category (i.e., those >85 years of age) is the most important age group, since it is the fastest growing. The number of elderly in this group has increased faster than any other age category, increasing over 200% during the last 25 years. By 2050, at least one-half of Americans will survive to their 85th birthday and will number 15 million, comprising 5% of the total US population. The oldest-old group incurs intractable problems of ill health, dependency, and loss. It also demands the highest level of health services. This group has the highest hospitalization rate, more than 50% higher than the general
Depression is not a normal process in the elderly population. The incidence of depression in the communitydwelling elderly is less than 3%. In hospitalized elderly patients, the prevalence of depression is estimated to be from 6% to 11.5%. Long term care facilities (LTCF) have a much higher prevalence of depression in their geriatric population. Estimates are that 15% to 25% of the existing population of the LTCF are clinically depressed. The incidence of new episodes or symptoms of depression are reported in approximately 31% of recently admitted first time LTCF residents. Increasing numbers of older Americans are expected to add to the demand for care of depression. As the population matures, the higher incidence of geriatric patients in both LTCF and the general population will represent a significant burden on the health care system.
This patient population currently utilizes physician services and hospital days at 30% and 380% greater rate respectively than the general population. As the geriatric population increases, there are no data to suggest that these rates will decrease. Therefore, the impact of depression on the health care system will remain significant. Depression imparts a substantial economic burden upon the health care system. The cost of treating depression is estimated at $43.7 billion each year in the United States; the direct costs amount to $12.4 billion. Indirect costs have been quantified for working adults in terms of absenteeism, lost productivity, and lost wages of those who commit suicide. A dollar value has not been placed on the diminished quality of life experienced by retired Americans with depression.
Risk factors for depression in the elderly are the same as in young adults. Certain risk factors--such as loss of a spouse, social isolation, and chronic medical conditions--are particularly common among elderly patients. Depression in the older population is more frequently a recurrence of disease, since first episodes of depression usually occur before age 50.
No matter what the disease state, the elderly should not be dosed in the same fashion as younger patients. In general, elderly patients should be initiated on therapy cautiously and slowly titrated up to effective doses. (The adage for dosing elderly, �Start low and go slow�, is good advice for dosing in this patient population.) In most cases, the main treatment of depression will involve the use of drugs. For patients who do not respond to drug therapy, electroconvulsive therapy (ECT) is a safe and effective alternative.
In general, all of the available drugs for the treatment of depression are equally effective. However, a patient who does not respond to one antidepressant may respond to another type of antidepressant or even another agent in the same classification. The antidepressants mainly differ in their mechanisms of action and side effect profiles. These differences are related to the neurotransmitter systems that are affected by each
The main neurotransmitters involved in treating depression are serotonin, dopamine and norepinephrine. The antidepressants vary in mechanism between blockade of reuptake, direct effects on receptor types or a combination of both at these receptors. Other receptors affected include histamine receptors, muscarinic receptors, and alpha 1 adrenergic receptors. It is the latter group that largely determines the side effects profile of the various antidepressants.When initiating drug therapy in the elderly, critical factors to consider are efficacy, tolerability, concomitant disease states and current medications. Ideally, the drug will have a rapid onset of action, no side effects, no drug interactions, and minimal toxicity. Of course, the perfect drug does not exist and all the available agents have side effects. These drugs can interfere with other medications and affect concomitant disease states. The goal of this article is to provide a brief overview of the available agents and potential benefits and
The main agents discussed here are the tricyclic antidepressants, selective serotonin reuptake inhibitors, trazodone, nefazodone, bupropion, venlafaxine, and mirtazapine. The most commonly prescribed and most widely used are the tricyclic antidepressants and the selective serotonin reuptake inhibitors. The monoamine oxidase inhibitors were the first antidepressants; but due to significant risk of food and drug interactions, they are often used as last-line therapy in patients who are unresponsive to other
In this discussion, all the tricyclic antidepressants will be referred to as a group. Some literature differentiates the group into tertiary amine and secondary amine tricyclic antidepressants (TCAs). The potency at different receptors may vary. Amitriptyline, doxepin, imipramine, desipramine, nortriptyline, and protriptyline all fall into this class. TCAs primary mechanism of action is blocking the reuptake of serotonin and norepinephrine. In addition, the TCAs block muscarinic cholinergic receptors, alpha 1 adrenergic receptors and histamine receptors. The effect on various neurotransmitters accounts for the multitude of side effects seen with the TCAs, especially at full therapeutic antidepressant dose, and accounts for the serious toxicity seen in
Effects of blockade at the muscarinic cholinergic receptors or acetylcholine blockade include blurred vision, dry mouth, tachycardia, constipation, urinary retention, and memory and cognitive function deficits. Alpha 1 adrenergic blockade leads to orthostatic hypotension and syncope. Antihistaminic effects include sedation and weight gain. Taking these factors into account, it is easy to see that the TCAs are probably not the drug of choice in a depressed Alzheimer�s patient or a patient with chronic constipation.The TCAs have shown broad efficacy and can have uses in multiple other disease states. Dose titration (the adage, �start low, and go slow�) in the elderly is vital to their effectiveness. Unfortunately, due to side effects that are especially deleterious in elderly patients, their use as antidepressant therapy is limited in the aged. The next major class of antidepressants are the selective serotonin reuptake inhibitors (SSRI�s) which include fluoxetine, paroxetine, sertraline, and fluvoxamine. As their name describes, these agents selectively block the reuptake of serotonin. These drugs have no clinically significant effects on acetylcholine, histamine, or adrenergic receptors. Thus, the side effect profile is greatly improved over the TCAs. However, agitation and akathisia (type of motor restlessness) are observed, especially with fluoxetion. Drugs in this class produce a higher incidence of sexual dysfunction, especially anorgasmia in women and delayed ejaculation in
Side effects resulting from the reuptake blockade of serotonin include gastrointestinal symptoms (anorexia, nausea and vomiting), anxiety, insomnia or sedation, and sexual dysfunction. GI symptoms and anxiety/agitation are the most common therapy limiting concerns with the SSRIs. Advantages to the SSRIs include: an improved side effect profile compared to the TCAs, ease in dosing, safety in overdose, and improved patient tolerance. Disadvantages include potential drug-drug interactions due to their inhibition of the cytochrome P450 enzyme in the liver and sexual dysfunction. The potency and specificity of inhibition of the cytochrome P450 enzyme system varies between agents. Fluoxetine in this regard has the potential for more drug-drug interactions. Whether this is clinically significant or not is still under
Trazodone is another antidepressant that has a complex mechanism of action. Trazodone has serotonin reuptake blocking properties as well as serotonin antagonist properties at
some serotonin receptor sites. In addition, trazodone has antihistaminic and alpha 1 receptor blocking actions. Its primary side effects include sedation and orthostasis. Due to the sedation, trazodone is often used at bedtime to aid in patients who may have insomnia or sleep disturbances. Trazodone may also be useful as add-on therapy with another antidepressant such as a SSRI. It also has a favorable toxicity profile and has been shown to have a slight positive effect on sexual dysfunction caused by
Nefazodone is very similar to trazodone, but with much decreased histamine blocking properties. Its main drawback is the potent inhibition of the cytochrome P450 3A3/4 enzyme system. This enzyme system is responsible for the metabolism of cisapride, terfenadine and astemizole. The potential exists for serious and sometimes fatal drug-drug interactions when given in combination with the above agents. Bupropion�s mechanism of action involves the reuptake blockade of dopamine and norepinephrine. The relative lack of action on the serotonergic system decreases the high incidence of sexual dysfunction seen with the SSRIs. Side effects due to the effects on dopamine include aggravation of psychosis, psychomotor activity, vigilance, and anxiety. The primary drawback to bupropion is the risk of seizure in high doses or overdose. It should be avoided in patients with a prior history of
Venlafaxine is a newer agent that blocks reuptake of serotonin, dopamine, and norepinephrine. It is very similar to the tricyclic antidepressants but lacks much of the cholinergic, histaminic, and alpha 1 adrenergic blocking properties. Side effects include headache, anorexia, nausea, and agitation. Its primary drawback is venlafaxine�s ability to induce hypertension. Thus, its usefulness in elderly patients is somewhat limited.Mirtazapine has effects on various serotonin receptor subtypes. Its place in therapy is still unknown. The most common side effect encountered is somnolence. In one study it was shown to improve sleep patterns and therefore might be useful in patients with sleep
Depression is a serious health problem for the elderly, with higher prevalence in patients who reside in medical care facilities. Depression is not a normal part of the aging process; and with prompt diagnosis and proper treatment, the quality of life of these patients will be improved. Usually, the SSRIs are the most appropriate medications for initiating antidepressant therapy in elderly patients. Trazodone and mirtazapine are useful as add-on therapy in combination with SSRIs especially in patients experiencing insomnia or other sleep disturbances. For patients that cannot tolerate SSRIs, alternatives such as buproprion and nefazodone are available.
Pharmacy Claims with Invalid Prescriber Numbers
The Louisiana Medicaid Pharmacy Benefit Management System (LMPBMS) has been reviewing pharmacy claims with invalid prescriber numbers. We have previously submitted reports to providers alerting them to the use of invalid prescriber numbers as well as generating an educational edit which informs providers that a prescriber number is invalid. Some pharmacies are submitting DEA numbers in the prescribing number field. Pharmacy providers generally use the hospital provider number when the physician does not have a Medicaid prescriber number or when the physician�s name is not legible in order for the pharmacist to determine the physician�s name and Medicaid prescriber
In order for the components of the LMPBMS, including the drug utilization reviews, the disease management interventions and outcomes management reports to be administered properly and for integrity to be maintained, it is necessary for claim information, including the prescriber�s number, to be submitted accurately to the Medicaid Program. By submitting the correct prescribing provider number of all Medicaid prescribing practitioners, the LMPBM can assure that the prescribing practitioner receives the educational and interventional material in the delivery of health care services for their Medicaid
The Department of Health and Hospitals staff, in affiliation with the Louisiana Academic Medical Centers/Hospitals, has assigned each hospital-based resident an individual prescriber number for pharmacy providers to utilize when billing for a Medicaid recipient. Residents may stamp or write their individual prescriber number on every prescription written for a Medicaid recipient.In the event a resident has not included his/her prescriber number on the prescription, the pharmacist may contact the following individuals at the institutions listed
Baton Rouge General Medical Center Family Residency Program
Contact Person: Tara Wilson
Phone: (504) 381-6689
LSU Medical Center - New Orleans
Contact Person: Liz Small
Phone: (504) 568-8632
Tulane University - New Orleans
Contact Person: Jessie Brubacher
Phone: (504) 588-5464
LSU Medical Center - Shreveport
Contact Person - Patricia Palmer
Phone: (318) 675-5054
Ochsner Medical Foundation
Contact Person: Elaine Orr
Phone: (504) 842-3260
In the past, pharmacists have been allowed to utilize the hospital�s provider number when completing their claims. With the issuance of the residents� prescriber numbers, the Department will no longer allow the hospitals to use their own provider numbers when a resident is in
We are also advising pharmacy providers that physicians who are delivering services to Medicaid patients in the mental health clinics have also been assigned individual prescriber
Effective July 1, 1998, the Department will:
Deny pharmacy claims with alpha characters, spaces, all zeroes and invalid prescriber numbers in the prescriber identification field. The edit will be 121-Missing or invalid prescriber identification, which is linked to NCPDP rejection code
Submit an educational message when using a prescriber number which is not linked to a provider type which has the authority to prescribe. Facility provider types not authorized to prescribe pharmaceuticals include hospitals and clinics (mental health, rural health, Federally Qualified Health Clinics (FQHCs), school-based clinics, public health, substance abuse clinics, etc.). This educational message will deny beginning on September 1, 1998. The edit will be 450 - Non-matched prescriber identification- which is linked to NCPDP rejection code
If you are unsure of the prescriber number of a physician who is not affiliated with one of the academic medical centers, please contact the Unisys Point of Sale Help Desk at 1-800-648-0790. If there is no record of a prescriber number for the physician, contact the Provider Enrollment Unit at (504) 342-9454 and a prescriber number will be assigned.
Timely Filing for KIDMED Providers
This is a reminder that all KIDMED claims must be submitted to Unisys within 60 days of the date of service in order to comply with the timely filing guideline. The timely filing requirement is critical to the accurate tracking and scheduling of KIDMED screening services for eligible recipients. Claims received after the maximum timely filing date cannot be processed unless the provider is able to furnish proof of timely filing. Such proof would be one of the following that has claim-specific information:
Remittance Advice indicating the claim was processed earlier (within the timely filing period).
The KIDMED Reports CP-0-115 (Recycled Claims Listing), CP-0-50 (Denied Claims List), or CP-0-51 (Electronic Media Claim Proof List) indicating the claim was received and/or processed earlier (within the timely filing
Correspondence from either the state or parish Office of Eligibility Determination concerning the claim and/or the eligibility of the recipient. The medical referral form from the MAP Units (Form 6-MAP) will not be accepted as
It is the provider�s responsibility to ensure that office software for electronic claim submission is functioning properly or that there is a reliable, efficient method to ensure that paper claims are submitted in a timely fashion. Overrides will not be made for provider errors that cause late filing of
It is also the provider�s responsibility to track claims submission and processing through the KIDMED reports or Remittance Advices and promptly resolve any outstanding claims. Unisys will not accept faxed, written lists or phone requests for the status of more than five claims.
Notice to EPSDT Health Services Speech Pathologists and
Clarification on Professional Requirements:
Speech Pathology Services must be provided by or under the direction of a speech pathologist or audiologist in accordance with the licensing standards of the Louisiana Board of Examiners for Speech Language Pathology and Audiology. Federal regulations also require that the speech pathologist or audiologist
Be the holder of a certificate of clinical competence from the ASHA;
Have completed the equivalent education requirements and work experience necessary for the certification;
Have completed the academic program and be in the process of acquiring supervised work experience to qualify for the
Medicaid does reimburse for speech-language pathology assistants providing EPSDT Health Services under the direction of a licensed speech-language pathologist.
�Under the direction of� means that supervision of such services must be in accordance with supervisory requirements of the Louisiana Board of Examiners for Speech Language Pathology and Audiology. For EPSDT Health Services�
Speech Pathology Assistants serving the Part H (Part C) population, Medicaid requires the following additional supervision: A minimum level of supervision of at least once a week, and no less than one visit per month per child served. Special instance: With home visits, supervision shall be increased upon recommendation of the supervisor in keeping with protection of the child�s safety, health, and welfare.
EPSDT Health Services Providers: New Reimbursement Rates
New reimbursement rates are in effect for EPSDT Health Services� Occupational Therapy, Physical Therapy, and Speech/Language Therapy. School Boards have certified availability of the state match for all EPSDT Health Services. Therefore, the rates for School Boards will reflect the cutback percentage of the state match and the amount of the check will be for only the federal portion, effective with dates of payment beginning March 1,
School Boards and Early Intervention Centers may adjust claims paid since March 1, 1998 to reflect the rate changes for dates of service to January 1, 1998. The codes and new rates are listed below.
|| New Rate
Improper Use of 158-A Extension Forms
We are finding that 158-A Extension Forms are being submitted requesting extension of visits for prenatal pregnancy codes. Please be aware that there is no extension mechanism for prenatal pregnancy codes, and 158-A�s should not be used for this purpose. Any requests for extension of these codes will not be approved.
Medicaid to Deny Nebulizer Medication Claims
Louisiana Medicaid pharmacy providers have previously been notified of Medicare Part B coverage of nebulizer medications. Presently, these claims are adjudicated with an educational message advising providers to bill Medicare. Effective June 1, 1998, Medicaid will deny these nebulizer medication claims with edit #434, which is linked to NCPDP edit #41 - Submit to other processor or primary carrier. Pharmacy providers billing nebulizer medications for Medicare Part B eligible recipients will be required to file those claims with the Medicare carrier. The Palmetto Government Benefits Administrators will automatically cross over the claim information to the Medicaid fiscal intermediary for payment of the coinsurance and deductible amounts where applicable.
We are providing the following information from the Medicare Region C DMERC Supplier Manual, Autumn 1997, for your billing
Obstructive Pulmonary Disease Patients (ICD 9 Codes 491.0 - 505)
|| Cromolyn sodium, unit dose form, per 10
|| Albuterol solution, concentrated form, per
|| Albuterol solution, unit dose form, per
|| Isoetharine solution, concentrated form, per
|| Isoetharine solution, unit dose form, per
|| Isoproterenol solution, concentrated form, per
|| Isoproterenol solution, unit dose form, per
|| Metaproterenol solution, concentrated form, per 10
|| Metaproterenol solution, unit dose form, per 10
|| Ipratropium solution, unit dose form, per
|| Sterile saline or water, up to 5 cc
|| Water, distilled, 1000 ml
|| Saline solution, per 10 ml, metered dose
Cystic Fibrosis Patients (ICD 9 - 277.00)
K0514 - Dornase alfa, unit dose form, per milligram*
HIV Patients (ICD 9 - 042)
J2545 - Pentamidine Isethionate, per 300 milligram*
Thick and Tenacious Pulmonary Secretions (ICD 9 - 786.4)
K0503 - Acetylcysteine solution, unit dose form, per gram*
* Please note that Medicare billing units are represented by milligram or gram strengths as opposed to milliliters for Medicaid billing purposes. A unit dose form is defined by Medicare as that preparation which is used for a single treatment or administered without adding any separate diluent. Concentrated forms are those dispensed to the patient which require a diluent prior to patient administration.The HCPCS modifiers used when billing unit dose nebulizer medications are as
|| Single drug unit dose formulation
|| First drug of a multiple drug unit dose formulation
|| Second or subsequent drug of a multiple drug unit dose
Medicare information is available by contacting the following:
Team Services (claim, pricing, and payment help) - (803) 691-4300
Electronic Data Interchange (connectivity and electronic services) - (803)
National Supplier Clearinghouse (supplier numbers) - (803) 754-3951
HCPCS Coding (procedure codes and modifiers) - (803) 736-6809
Professional Relations (general information) - (803) 735-1034
Anti-fraud hotline (fraud and abuse reporting) - (803) 788-5414
Providers are urged to thoroughly review the Medicare manuals and advisories for complete billing instructions.
Attention Pharmacy Providers:Billing Errors
The Pharmacy Program has reviewed claims for the new H. pylori treatment therapies and found billing errors in the quantity and days supply fields. Pharmacists should be aware of the following billing instructions when submitting Medicaid claims for these
Helidac therapy pack contains 14 dosage cards with each card containing 4 daily doses. Although each dosage unit contains 2 bismuth subsalicylate chewable tablets, one metronidazole tablet and 1 tetracycline capsule, the correct billing quantity for one full box of Helidac is 56 units. This quantity represents 56 doses per Helidac therapy pack. These 56 doses represent a 14-days supply. In order to bill correct quantities of Helidac therapy, pharmacists should submit quantities representing the total number of doses of Helidac dispensed, not the individual number of tablets and capsules
PREVPAC is packaged in a combo pack consisting of 14 cards (packs). Each unit reflects one full day�s therapy. The correct billing unit for one full box of PREVPAC is 14. This also represents a 14-days supply. To correctly bill for PREVPAC, pharmacists should submit the number of cards dispensed which always equals the day�s supply.
CPT Codes 11055 - 11057 Now Payable
CPT codes 11055, 11056, and 11057 - Paring and cutting of benign hyperkeratotic lesion - which are new codes in 1998 CPT, have been made payable effective with date of service January 1, 1998. Fees for these codes are listed below.
11055 - $15.26
11056 - $21.78
11057 - $23.76
A recycle of claim denials of these codes will be completed within the near future.
Fee Increase for Adriamycin
The Bureau of Health Services Financing is pleased to announce a fee increase for Adriamycin, 10 mg., Code J9000, effective with date of service May 15, 1998. The new fee is $43.64.
The Medical Assistance Program Integrity Law (MAPIL) Provider Agreements and Civil Causes of Action
The 1997 Regular Session of the Legislature passed and the Governor signed into law the Medical Assistance Program Integrity Law (MAPIL) cited as LSA-RS 46:437.1-46:440:3. This legislation has a significant impact on all Medicaid providers. All providers should take the time to familiarize themselves with the provision of this law.
This notice does not constitute a legal opinion by the department, nor is it all-inclusive. The purpose is merely to notify you of the existence of these new statutory provisions related to the Medical Assistance Program, including
The following is a very brief outline of some of the provisions of
MAPIL contains a number of provisions related to provider agreements. Provisions which deal specifically with provider agreements and the enrollment processes are contained in LSA-RS 46:437.11-46:437.14. The provider agreement provisions of MAPIL statutorily establish that the provider agreement is a contract between the Department of Health and Hospitals and the provider, and that the provider voluntarily entered into that contract. Among the terms and conditions imposed on the provider by this statute are the
--Comply with all federal and state laws and regulations;
--Provide goods, services, and supplies which are medically necessary in the scope and quality fitting the appropriate standard of
--Have all necessary and required licenses or certificates;
--Maintain and retain all records;
--Allow for inspection of all records by governmental authorities;
--Safeguard against disclosure of information in patient medical records;
--Bill other insurers and third parties prior to billing Medicaid;
--Report and refund any and all overpayments;
--Accept payment in full for Medicaid recipients providing allowances for copayments authorized by
--Agree to be subject to claims review;
--The buyer and seller of a provider are liable for any administrative sanctions or civil
--Notification prior to any change in ownership;
--Inspection of facilities; and
--Posting of bond or letter of credit when required.
MAPIL�s provider agreement provisions contain additional terms and conditions. The above is merely a brief outline of some of the terms and conditions.
The provider agreement provisions of MAPIL also provide the Secretary with the authority to deny enrollment or revoke enrollment under specific
The effective date of these provisions was August 15, 1997. All providers who were enrolled at that time or who enroll after that date are subject to these
Civil Causes of Action
MAPIL also contains provisions which set out civil causes of action related to the Medical Assistance Program. There are four provisions that cover activities which can give rise to a civil suit against persons operating under the Medical Assistance Program: Illegal Remunerations (Anti-kickback and Anti-Referral provisions) LSA-RS 46:483.2, False or Fraudulent Claims or Misrepresentations LSA-RS 46:438.3, Illegal Acts Regarding Eligibility and Recipient Lists LSA-RS 46:438.4 and Civil Monetary Penalties LSA-RS 46:438.5. All persons involved in providing goods, services or supplies under the Medicaid program must be familiar with these
These provisions were effective apply to all goods, services or supplies which were provided on or after that
Civil causes of actions under these provisions may be brought by the Department and/or the Attorney General (LSA-RS 46:438.1). Recovery may include actual damages, liquidated damages, fines, civil monetary penalties, costs, expenses, fees and attorney fees. Liquidated damages may include an amount which is three times the actual damages suffered by the Medical Assistance Program. Any awards under MAPIL are in addition to any other criminal fines or penalties which may be imposed under LSA-RS 46:438.1, 46:438.5,
As a means of protecting any possible recovery and enforcing recovery of any judgments rendered in court or through administrative proceedings, the department and/or the Attorney General may seek injunctive relief which can including placing lis pendencs on all assets and appointment of a receiver to prevent disposal of assets (LSA-RS 46:437.6). Additionally, property which is traceable to any monies owed can be subject to forfeiture in order to satisfy the payment of an award to the Medical Assistance Program. Awards are granted a privilege over certain other liens and are not dischargeable through bankruptcy per LSA-RS 46:437.9. Those who sell, merge, consolidate, dissolve or otherwise liquidate assets of a provider shall remain liable for the award. Any person who purchases, merges or consolidates with a provider who has an award imposed on it shall assume responsibility for payment of any unpaid portion of the award at the time of the transaction (LSA-RS
These provisions of MAPIL should be reviewed with great care by any person who participates in Medicaid.
Qui Tam Suits
MAPIL provides private individuals the authority to bring a civil action and obtain a share of any recovery, as long as they are the original sources of information establishing that an illegal remuneration, false or fraudulent claims, or misrepresentations or acts regarding eligibility and recipient list have occurred in violation of MAPIL. Qui Tam suits are governed by special procedures established under MAPIL. Refer to LSA-RS 46:439.1439.4.
Persons who file Qui Tam actions or provide information to the department or Attorney General are protected from adverse action taken by the provider and others and may sue those who engage in adverse actions. See LSA-RS
An individual who provides information that leads to the imposition of an administrative sanction or a judicial award may be given a reward of up to $2,000 for providing that information (LSA-RS
MAPIL provides protection from liquidated damages and other awards over and above actual damages if the person committing the violation reports the violation to the proper authorities prior to an investigation into the alleged violations being instituted (LSA-RS
Claims Review and Administrative Sanctions
MAPIL also provides for claims review and the imposition of administrative sanctions, including posting security, recoupment, monetary penalties and exclusions per LSA-RS 46:437.4 and 46:437.3 (26).