We are excited to share the new NAMPI member portal with our NAMPI 2025 attendees! Please edit your profile in the top right corner to claim your NAMPI St. Louis Pin! Helping us complete profiles will greatly enhance the search capabilities of the member directory and allow you to connect with members who may have the specific information you…

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We are excited to share the new NAMPI member portal with our NAMPI 2025 attendees! Please edit your profile in the top right corner to claim your NAMPI St. Louis Pin! Helping us complete profiles will greatly enhance the search capabilities of the member directory and allow you to connect with members who may have the specific information you…

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Illinois does not utilize TMSIS for PERM but does use for our UPIC contractor. PERM has direct access. For UPIC, there are discrepancies but that could be explained from the delayed MCO encounter data.

Illinois: 89 Ill. Admin. Code, Section 140.15 Suspension and Denial of Payment, Recovery of Money and Penalties

…

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Idaho’s administrative rule IDAPA 16.05.07.205 states the Department may recoup the amount paid for items or services listed in Section 200 of these rules. In Section 200, it states the Department may deny payment for services not provided or not medically necessary, contrary to rules or provider agreement, or for failure to provide…

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Hi all, we are wondering if your state has Administrative Code that permits recoupment based on policies and topics in your Medicaid handbooks. If so, could you please provide a link to your state’s admin code? Thank you!

Good morning! Wisconsin would be happy to share our MOU via email. Please send me your email address. Thanks!

Thank you so much Rebecca! I appreciate your answer.

Hello, it’s a valid question. We (Louisiana) have asked questions like this to our actuaries before, and generally the actuaries tend not to be concerned about SIU or Program Integrity recoveries, because the service dates tend to be old enough that they do not affect future rates. Our MCOs report financials quarterly, including income…

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Jennifer .. I will send Missouri’s to you .. please email me at Dale.Carr@dss.mo.gov and I will respond with the MOU.

Dale Carr, Director, Missouri Medicaid Audit & Compliance

Maryland is revising its MOU with the MFCU. I am interested in reviewing other State’s MOUs prior to making any changes. Anyone willing to share their MOU? Thanks!

We are trying to get finders’ keepers language added to our MCO contract. Our Division of Medicaid Services was concerned that either the actuaries or the contracting area of CMS may have issues with the addition of this language.

Have any other states ever had problems getting their MCO contract approved due to finders’ keepers language, or…

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Wisconsin OIG is still working with our Medicaid policy partners to try to establish recovery of network provider overpayments. We are trying to establish a finders’ keepers model with OIG recovering from the MCO and the MCO recovering from the network provider. Our partners are having difficulty visualizing how the federal reporting would work…

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My organization would like to perform a program integrity compliance assessment. However, we do not have a starting place or resources to reference to begin such an assessment. Can anyone provide any suggestions or recommendations?

I’ve already shared with Hawaii but also sharing here:

<font color=”#000000″>We (AZ) house our policy for denials and terminations in the same policy. Based on this discretionary language, if we identify fraud, waste, and abuse concerns, or health and safety concerns when going through the screening process for a provider seeking to enroll, we…

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Hello,

Massachusetts is beginning to implement a policy that I know has been implemented in other states where will will begin to share a certain portion of MFCU recoveries with MCE’s if they have made a referral of the provider that led to the recovery. CMS has said that it’s fine to have such an arrangement in our contracts with the MCE’s…

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The Illinois Administrative Code allows for a provider’s termination of enrollment when the provider in question “engaged in practices prohibited by applicable federal or state law or regulation.” See Ill. Admin. Code tit. 89, sec. 140.16(a)(10)(A)(i). But that overarching provision is later limited to eight categories of crimes that, upon…

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Kurt,

The previous link I sent did not work. I have attached a pdf version of our Administrative and Billing Manual.

V/r,

Duane

Kurt,

Here is something we have in South Carolina in our Provider Administrative and Billing Manual:

Criminal Background Checks As a condition of enrollment in South Carolina Medicaid, SCDHHS requires that providers consent to criminal background checks, including National and State criminal record checks when they:

• Have a 5 percent or more…

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Kurt .. I have provided a link to our Missouri Medicaid provider sanctions regulation. It is somewhat broader than your state’s rules:

Missouri Secretary of State: Code of State Regulations

mo.gov)https://www.sos.mo.gov/cmsimages/adrules/csr/current/13csr/13c70-3.pdf

Look specifically at 13 CSR 70-3.030(3)(A)(32)

Best regards .. Dale Carr

Hi Kurt, North Dakota Admin Code allows denial & termination for the following non-Medicaid related offenses that may affect the ability of the quality of the care or the integrity of the provider, see 75-03-23-07(2)(b)(c); 75-03-23-08, 75-03-23-08.1. Qualified service provider standards…

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From Oregon: OAR 410-120-1400

https://secure.sos.state.or.us/oard/viewSingleRule.action?ruleVrsnRsn=306658

In Washington State the rules for termination of a provider are very broad and can be based on either cause or for convenience. I have attached a link to these rules below.…

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Aloha NAMPI colleagues,

In Hawaii we have been challenged by our administrative hearing officers regarding termination of providers for criminal offenses not involving fraud or other Medicaid related offenses. They have ruled that the wording of our administrative rules does not specify we can terminate providers for other criminal offenses.…

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NAMPI Colleagues,

I received a great recommendation to post this survey to this forum. Iowa Bureau of Program Integrity and Compliance is conducting a survey to collect resources of various state’s authorities relating lookback period for making non-fraud related overpayment recoveries. The survey result will be shared with you if…

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Share your thoughts, questions, and ideas from our most recent webinar (Wednesday, November 15 @ 2 PM ET) with the NAMPI community! The recording and slides will be available in your member portal next week.

Thank you to our wonderful speakers for sharing their time and expertise! Feel free to reach out to them with any follow-up…

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Utah just used NASPO to procure a case management system.

Have any states been successful at obtaining a SURS (Surveillance Utilization Review Subsystem) and/or Case Management System via NASPO?