HMS details five automated RAC scenarios; providers press for clarity on records and rebilling
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Summary
HMS presented five automated audit scenarios — duplicate behavioral-health claims, pediatric behavioral therapy place-of-service and provider-type issues, missing ordering providers, and NEMT trips without a qualifying medical claim — and providers raised concerns about FQHC exceptions, record burdens for disputes, and the automated approach to high-volume services.
Matt, an HMS presenter, walked the advisory board through five audit scenarios the vendor will apply as automated checks. He described the first as exact duplicate behavioral-health claims: "same date of service, same member, and same provider" billed to both a regional behavioral-health entity and fee-for-service, which would be flagged for recovery if both are behavioral-health services.
HMS described three pediatric behavioral therapy (PBT) checks: claims with disallowed place-of-service codes (with location code 03 for schools allowed beginning 05/03/2024), claims billed by incorrect provider types (noting a change in provider-type coding/enrollment referenced), and claims missing an ordering, referring or prescribing provider on the claim. Matt emphasized federal HCPCS/HCPF policy requires the ordering/referring provider element be present and said the automated audit will identify claims that lack it.
The final scenario targets nonemergency medical transportation (NEMT) trips without a corresponding medical claim at the destination. Matt explained the audit looks for trips where the destination does not correspond to a covered service and that NEMT trip logs (drop-off address, attestation the trip was to a medical facility) will be used by providers to overturn flags when appropriate.
Providers pressed multiple practical questions. Shauna and others asked how FQHC encounter rules and multiple same-day encounters are handled; HMS replied that the automated flag focuses on overlapping behavioral-health claims and that known exceptions (for emergency/inpatient transfers or FQHC-specific billing) should not be wrongly flagged. Providers also asked why the vendor doesn't request trip records proactively rather than flagging by algorithm; HMS and department staff said manual record review is time-consuming at NEMT scale and that automation narrows the set of claims for which providers must supply records.
Alex, who oversees the department's NEMT program, and Ashley from the fraud, waste and abuse division said investigations are available where patterns indicate abuse — they reported that abuse is often associated with provider billing patterns and that investigators use trip addresses and attestations to detect trips to nonmedical locations.
HMS staff said the automated approach is intended to be a first filter; providers can dispute specific flags and submit documentation for record review. Staff invited providers to volunteer for pilots and to help test rebilling processes so the department can smooth operational issues ahead of a broader launch.
Next steps: HMS will publish or maintain guidance on the vendor portal and providers should confirm contact info in the HMS provider portal and the interchange to ensure audit notices reach the right teams.
