New York State Medicaid Included In The PERM Project

If a New York doctor accepts Medicaid and practices in New York that may be enough be included an audit program conducted through a project known as Payment Error Rate Measurement Program (PERM).

The Centers for Medicare & Medicaid Services (CMS) developed the PERM project to comply with the Improper Payment Information Act (Act). In general, the Act requires that heads of Federal agencies annually review programs that are susceptible to significant erroneous payments, estimate the amount of improper payments, report those estimates to Congress, and submit a report on actions the agency is taking to reduce erroneous expenditures.

According to the Office of Management and Budget, Medicaid and CHIP are programs at risk for significant payment error.

The New York State Medicaid Program is one of 17 jurisdictions that is included in the current cycle of review by PERM. CMS uses a 17-State rotation cycle for PERM whereby each state is reviewed once every three years.

What Should Providers Expect?

CMS has contracted with A+ Government Solutions to review providers’ service documentation for a random sample of Medicaid fee-for-service payments made between October 1, 2010 and September 30, 2011. The review is targeted at the medical documentation to determine if the services complied with applicable Medicaid rules and whether providers were improperly paid.

Providers selected for review will be contacted by A+ Government Solutions to provide records to substantiate the paid claim. Such communication should “clearly explain the documentation needed; when it is due; and where to send it.”

HIPAA Concerns?

According to CMS, the PERM Review Contractor activities performed are authorized by HHS regulations at 45 C.F.R. 164.512(d), which permit disclosure of protected health information contained in medical records for payment review purposes and oversight activities.

Failure to Respond

CMS deems failure to respond within the 75 day time frame as constituting an improper payment subject to recoupment. CMS equates failure to provide records with “no evidence to adequately determine whether the services were provided, were medically necessary and were properly coded and paid.”

Important to note for New York providers is the additional requirement of having to provide a copy of the documents requested by a PERM contractor to the NYS Office of the Medicaid Inspector General (OMIG).

PERM review is separate from other audits that may be conducted by the Recovery Audit Contractors (RACs) or Medicaid integrity audits.