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Medicaid Vendor Drug Program Study Appendices

Table of Medicaid Vendor Drug Program Study Appendices

Appendix B.1: Vendor Drug Program Study Participants

Organization Description of Role
Comptroller of Public Accounts Provided overall project management. Solicited bids and selected a contractor for the study. Evaluated and enhanced study design from the first study. Coordinated project meetings, interviews, and information requests from all agencies involved with the Medicaid, State Employees Workers' Compensation and Medicaid Managed Care studies. Compiled and validated all study information received. Worked with consultants on aspects of the study, including completing information sheets, assisting with medical record review, and resolving issues as they arose.
Ethel Ponson, R.N. Professional nurse utilization reviewer. Reviewed online claim information and medical record documentation received from providers for the study. Assisted with the compilation of the results and interagency medical record review meetings.
ECS Consultants Professional nurse utilization reviewer. Reviewed online claim information and medical record documentation received from providers for the study. Assisted with the compilation of the results and interagency medical record review meetings.
Health and Human Services Commission
Office of Eligibility Services
Mailed notification/information request letters to the Medicaid sample clients. Coordinated the Medicaid provider medical record request mail-outs. Received and tracked the medical records for delivery to the Comptroller's office. Responded to the Medicaid providers' inquiry calls. Coordinated TDH, NHIC, physician and dental agency reviews of the Medicaid medical records.
National Heritage Insurance Company
(02-03 HHSC Medicaid Claims Administration Contractor)
Created the Medicaid sampling program and collected the sample report data using study criteria developed by the Medicaid study project team. Compiled the sample universe data and fiscal claim data.
State Auditors Office Provided assistance with evaluating and enhancing the Medicaid study methodology. Validated the Medicaid sample universe data. Performed the overpayment rate computation.

Appendix B.2: Vendor Drug Program Organization Chart

 Vendor Drug Program Organization Chart

Appendix B.3: Medicaid VDP Study Sampling Procedure

Step 1 (SQL) - Pull VD claims from which the sample records will be chosen as defined by requestor.


SourceSQL: $libr01.axapahqp.ah1749ua Output data: $daw109.pdapadpm.ah1749ua
SourceSQL: $libr01.axapahqp.ah1749ub Output data: $daw112.pdapadpm.ah1749ub
SourceSQL: $libr01.axapahqp.ah1749uc Output data: $daw115.pdapadpm.ah1749uc

Step 2 (SQL)- Inserted all records into $DAW112.PDAPADPM.ah1749un, but can not find code or log


Source SQL: $libr01.pdapaxap.ah1749d1 and ah1749d2
Input data: $daw109.pdapadpm.ah1749ua
Input data: $daw112.pdapadpm.ah1749ub
Input data: $daw115.pdapadpm.ah1749uc
Output: $DAW112.PDAPADPM.ah1749un

Step 3 (C) - Randomly choose 1 record per client from sample universe


$libr02.axapddef.vdstudy
Input data: $DAW112.PDAPADPM.ah1749un
Output data: $daw113.pdapadpm.ah1749ud
Program: $libr02.aoaphext.Vkrandip

Step 4 (C) - Randomly choose 300 sample records from de-duped universe


Input data: $daw113.pdapadpm.ah1749ud
Output data: $DAW113.PDAPADPM.AH1749US
Program: $libr02.aoaphext.vrandcgl

Step 5 (SQL) - Pull associated Vendor drug claims to sample records


Source SQL: $LIBR01 AXAPAHQP.ah1749av
output data: $daw113.pdapadpm.ah1749av

Step 6 (Business Objects report)-Pull Medical claims for 300 PCN from Vendor Drug Sample
Extra steps:

  • Pull Submitted RX amount for the de-duped universe. Do not need Drug Cost amount originally pulled.
  • After pulling the RX amt and replacing what was in the COST AMT column, I remembered that I had the PAID AMOUNT of de-duped universe table(ah1749ud) was actually the COST AMT. These values were switched when I built the associated claim file(ah1749av), but not in ah1749ud. So, the result of pulling the RX submitted amt for the De-duped universe file(ah1749ud) was that I overwrote the PAID AMOUNT value that was actually in the COST AMT column. I then nulled out both column in ah1749ud and update both into the correct column.

Note: Files that contain the correct COST AMT AND PAID AMOUNT are AH1749AV- The associated claims

AH1749UD - The de-duped sample universe

Appendix B.4: Medicaid VDP Study Prescription Request Letter

seal

Texas Health and Human Services Commission

Albert Hawkins.
COMMISIONER

(Date)
CERTIFIED MAIL NUMBER
RETURN RECEIPT REQUESTED

Study ID Number:

(Provider name)
(Address)
(City, State, Zip)

Dear Provider:

NOTICE OF REQUEST FOR COPIES OF MEDICAL RECORDS

The Texas Health and Human Services Commission (Commission), Office of Investigations and Enforcement, is conducting a review of services paid by the Medicaid Vendor Drug Program for certain clients.

Under the authority of 42 CFR PART 456, Utilization Control, the Commission, identified as the Medicaid agency, is required to evaluate the need for and the quality and timeliness of all Medicaid services. To accomplish this evaluation, services, which have been billed under your provider number(s) to the Medicaid program, have been selected for a focused review. Also, under the authority of 42 CFR, 431.107(b)(1) and (2), you are required to retain and make records available as requested by the Medicaid agency within a reasonable length of time. This requirement is included in both your provider agreement and the Texas Medicaid Provider Procedures Manual, Part I, Retention of Records.

Please provide complete legible copies of the original patient prescription(s) from the prescribing physician or other authorized prescriber for each of the clients listed on the enclosed form. This request includes copies of any and all documentation supporting phone, verbal, fax and electronic prescription orders from the prescribing physician. If the prescription is a refill, send a copy of the original prescription along with a copy of the refill request. Account summaries, tax statements or electronic labels without the original prescription order are not considered acceptable documentation for this request.

In accordance with 25 Texas Administrative Code, Sections 79.2105(4), 79.2112, and 79.2115, sanctions will be imposed against you if you fail to provide the information as requested. Possible sanction actions may include, but are not limited to, vendor hold and/or exclusion from participation as a provider in the Texas Medicaid program, until the matter is resolved. Additionally, payments for services for which records are not produced will be recovered.

All patient prescriptions requested, must cover the date of service indicated on the enclosed list. The Commission is requesting that you provide the requested records no later than fourteen (14) days from the date that you receive this letter. Also, please have your records manager complete one records Affidavit form, copy enclosed, for each of the patients listed on the enclosure and place it on top of the corresponding patient record documentation that you provide. Please send the requested records by mail to:

Dee Kowalewski
Texas Health and Human Services Commission
Office of Investigations/Enforcement
Post Office Box 13247
Austin, Texas 78711-3247

If you have any questions, please call Dee Kowalewski at 512-482-3468 or Melanie Smith at 512-482-3447.

 
 
Sincerely,

 

Aurora F. LeBrun
Associate Commissioner
Office of Investigations and Enforcement

Enclosures

Records affidavit Records affidavit

MEDICAL RECORD REQUEST LIST

Provider Name: ___________________________
PO Certification No.: ______________________

Study ID No. Medicaid PCN Client Name Date of Birth Prescription Number NDC Date of Service Date Paid
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               
               

Appendix B.5: Medicaid VDP Study Discrepancy Error Code Table

Error Code Type of Error Code Error Code Description Overpayment Determination for Sample Service Review Error Action
A Documentation - No Receipt Documentation - No response to HHSC request for copy of original prescription Overpayment with recoupment of the paid amount of the sample service. Refer pharmacy provider to HHSC/OIG for further review. Recoupment if pharmacy cannot produce the original prescription from a prescribing physician.
B Documentation - No Original Prescription Documentation - No documentation of the drug prescription in the copies of original prescriptions received from the pharmacy Overpayment with recoupment of the paid amount of the sample service. Refer pharmacy provider to HHSC/OIG for further review. Recoupment if pharmacy cannot produce the original prescription from a prescribing physician.
C Documentation - Controlled Drug Documentation - Filling a prescription not compliant with 21CFR1306.05 prescription requirements: All prescriptions for controlled substances shall be dated as of, and signed on, the day when issued and shall bear the full name and address of the patient, the drug name, strength, dosage form, quantity prescribed, directions for use and the name, address and registration number of the practitioner. Overpayment with recoupment of the paid amount of the sample service. Educational letter to both the pharmacy and prescribing providers on required federal documentation requirements for a legal prescription of a controlled substance.
D Documentation - General Prescription Documentation - Original prescription (physician, fax, telephone or computer e-mail) does not have one of the following: date, patient name, drug name, dosage and directions for patient. Discrepancy without overpayment Educational letter to pharmacy or physician on prescription documentation standards. Refer provider and pharmacy to HHSC for further review and action.
E Medication The medication requested by the prescribing provider was not the same medication given to the client as per the prescription copy received by the pharmacy. Overpayment with recoupment of the paid amount of the sample service. Refer pharmacy provider to HHSC/OIG for further review to identify if a problem exists and recoup the total dollars paid on the claim for noncompliance of the Texas Medicaid law.
F Medication Filling a prescription for a medication that is contraindicated with other known drugs the client is taking or the client's diagnosis (if provided/known) Overpayment with recoupment of the paid amount of the sample service. Refer pharmacy provider to HHSC/OIG for further review to identify if a problem exists and recoup the total dollars paid on the claim for noncompliance of the Texas Medicaid law. Educational letter/visit to the pharmacy provider.
G Procedure Refilling prescriptions for long-term/rehabilitation Medicaid residents without confirming order with prescribing provider per TAC 19.1202 & 1203. Overpayment with recoupment of the paid amount of the sample service. Refer pharmacy provider to HHSC/OIG for further review to identify if a problem exists and recoup the total dollars paid on the claim for noncompliance of the Texas Medicaid law. Educational letter/visit to the pharmacy provider.
H Billing/ Processing Prescription claim with a drug that is not appropriate for the age of the patient Discrepancy without overpayment Refer pharmacy provider to HHSC/OIG for further review to identify if a problem exists and recoup/adjust the dollars paid on the claim. Educational letter/visit to the pharmacy provider.
I Physician There are no corresponding Medicaid medical visits for the client related to the prescription claim. Discrepancy without overpayment Refer to HHSC/OIG for further review of the pharmacy and prescribing provider.

Appendix B.6: Medicaid VDP Study Prescription Review Worksheet

 Medicaid VDP Study Prescription Review Worksheet

Appendix B.7: Medicaid VDP Sample Statistical Data Tables

Exhibit 1: Medicaid VDP Overpayment Calculation Table
  VDP Study
Total Number of Sample Prescriptions 4,036
Amount Paid for Sample Prescriptions $191,888.05
Total Number of Prescription Overpayments 916
Amount Paid for Overpayment Prescriptions $40,712.64
Point Estimate of Overpayment Error Rate 21.22%
Amount Paid for Universe of Paid Prescriptions $62,033,277.00
Lower 95% Confidence Interval 21.03%
Upper 95% Confidence Interval 21.40%
Margin of Error on Proportion of Sample Dollars Overpaid 0.18%

Exhibit 2: Medicaid VDP Study Computation of the Payment Accuracy Rate performed by the State Auditor's Office
Step Computation Description
1 Total dollars in the sample were calculated.
2 Total dollars in the universe were calculated.
3 The total dollars overpaid were calculated.
4 A point estimate of the overpayment error rate was calculated by dividing the number of dollars overpaid by the number of dollars sampled.
5 A margin of error at 95% confidence was calculated by taking the square root of [(1.96^2) x (point estimate x 1-point estimate)]/dollars sampled].
6 The above margin of error was multiplied by [1-(sample dollars/universe dollars)] to adjust for the finite universe.
7 The margin of error was added to and subtracted from the point estimate to render a 95% confidence interval.
8 The dollars in the universe were multiplied by the lower confidence limit, point estimate, and upper confidence limit of the 95% confidence interval to extrapolate the error rate to the universe of dollars.