MMAC Self Audit: Follow Up Information

Dear Pharmacist,

The Missouri Pharmacy Association (MPA) has been notified by the Missouri Medicaid Audit and Compliance (MMAC) Unit of the following:

For the thousands of claims that have been reviewed, MPA has not found any consistent or significant error in the way the claims were paid that could be resolved by action on the part of the pharmacy.  If from your research you were unable to determine over payments or errors,  MMAC suggests you respond with a comment indicating “there were no errors found from the data available to me on the self-audit.”

From MPA’s review of the situation, we note that the following information may prevent you from determining whether an overpayment exists:

  • The majority of the claims sent have a date of services greater than 5 years. Per provider contract with MO HealthNet, records are not required to be kept more than 5 years. Thus many records are unavailable to be audited.
  • Prescription numbers were not provided. Without the prescription number the records cannot, with absolute certainty, determine the specific claim referenced.
  • The majority of claims selected to self-audit appear to be MORx claims. MORx is a program that is entirely funded through State General Revenue dollars and “wraps around” the Medicare Part D benefit. The state system internally determines the benefit level after reviewing Medicare Part D. There appear to be some errors in the way the state system calculated the coordination of benefits amount on some Medicare Part D claims that received a MORx wrap-around payment. We do not have the data to determine the error level if any.
  • Providers have no opportunity to enter, calculate, or otherwise impact the amount of the coordination of benefit calculation made by your system. There were a small number of claims that appear to have a Medicaid benefit claim as primary for a Medicare Part D eligible patient. All of those reviewed indicated the Medicaid system showed no Medicare Part D eligibility on the date of service. If there was Medicare Part D eligibility the Medicaid system has an edit to block those claims so Medicaid is not primary. You can only assume the eligibility data was late, did not exist, or the edit was not working. You can respectfully request MMAC verify these important parameters in their system since you are unable to monitor.
  • For these reasons you may not see any benefit in reviewing additional years of prescription records.

In closing, MPA hopes that in the future when something of this magnitude arises MMAC would take a more in-depth look and get a better understanding of Medicare, Medicaid, and MORx. Many hours of research was required for us to try to determine what the issue was MMAC was trying to address. This could have been time better spent on both of our parts if MMAC would have reviewed a sample of the data with MPA first. MPA believes that anytime you have this volume of issues affecting this volume of providers it is likely there is a system error involved.


Ron L. Fitzwater
Chief Executive Officer

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