Self-Attestation Audit

BMS is required to audit a statistically valid sample of physicians who have self-attested to either Board Certification or a supporting claims/service history. Higher payments for both Fee for Service (FFS) and Manage Care Organization (MCO) services will be recovered from physicians who the audit determines were not eligible. For physicians attesting that 60 percent of their Medicaid claims for the prior year were for the E&M services and vaccine administration, BMS will count all West Virginia Medicaid claims paid by FFS and MCOs during the most recently completed calendar year or, for newly eligible physicians, the prior month. Denied and duplicate claims will not be included to meet the 60% threshold. Primary care services are all the codes covered by the enhanced payments, including vaccine administration codes. In the case of adjustments, only the final adjudicated claim will be counted. For providers claiming eligibility based on Board certification, certification will be audited. Providers should submit their Board Certification when they submit the Self-Attestation Form.

BMS will pursue repayment in all instances of improper or duplicate payment. BMS will recoup all paid enhanced primary care payments if the physician is found to be ineligible for this program.

Additional Resources
Please review the following documents from CMS for frequently asked questions and additional information for providers.

Federal Register Final Rule “Medicaid Program; Payments for Services Furnished by Certain Primary Care Physicians and Charges for the Vaccine Administration Under the Vaccines for Children Program”

http://www.gpo.gov/fdsys/pkg/FR-2012-11-06/pdf/2012-26507.pdf