What is the intended process for review and/or audits of services under the new MRO program?
The implementation of the transformation project will occur in stages, with DMHA working closely with CMHCs to conduct educational audits of both standard assessments and provided services prior to assessing any financial penalties. Additionally, the implementation of the service package model will include programming edits and audits into the Medicaid billing system that will limit the ability of a provider to receive Medicaid reimbursement for services that are not within a consumer’s level of need. Ultimately, it will be the CMHC’s responsibility to limit the provision of services to those within the consumer’s authorized service package and to request exceptions when clinically indicated. However, the program edits will help ensure that providers do not inadvertently bill for a large number of services which would be subject to recoupment in the case of a financial audit.
