Audit of ACA Enhanced Payments for Primary Care Coming this Week

In the coming days NC Medicaid will perform an audit of physicians, physician assistants, and nurse practitioners who attested and received enhanced payments under the ACA for certain primary care services provided in 2013 and 2014. The audit is required by federal law and is meant to confirm that those who attested and received the enhanced payment rates were eligible to receive them.

We have received advance details from the Division of Medical Assistance (DMA) and want to share those with you now. Please review the following carefully.


A sample of 100 physicians who attested that they qualified to receive the enhanced payments will be randomly selected for audit. For those selected, DMA will independently confirm that the physician was EITHER board certified in one of the applicable specialties/subspecialties OR that at least 60 percent of his/her Medicaid paid CPT codes were the ACA eligible codes for E&M and vaccine/toxoid codes. No work will be required on the part of those selected. In fact, if the audit confirms that an individual physician was eligible, the physician will likely never know he/she was audited.

However, if DMA believes that the physician was ineligible, DMA will contact the physician with a mailed notice that the supplemental portion of his her 2013-2014 Medicaid payments (not the entire claim payment) will be recouped. Furthermore, if a physician is deemed ineligible and also supervises a PA or NP that attested, the supplemental payments to that PA or NP could be recouped as well. DMA’s notice will describe how a physician may dispute the findings and pursue an appeal.

PAs and NPs

Because CMS requires a “paper trail” for the attested PAs and NPs, the process DMA has created for these providers is different. This week DMA will mail certified letters to every PA and NP who self-attested for the enhanced payments. The letter will be sent to the address tied to the person’s record in NCTracks.

The letter directs the PA or NP to complete and return the enclosed Midlevel Provider Confirmation form within 30 days. The short form requests the name of the PA’s or NP’s supervising physician, the physician’s NPI, and a signed statement that the physician accepts professional responsibility for the services rendered. Completed forms can be mailed (we suggest certified) or faxed (as a last resort – and please call to confirm receipt) to DMA. Review a draft of the DMA letter and Confirmation form.

DMA stresses that the form is only meant to generate documentation for each attested PA and NP. We understand that a PA’s or NP’s eligibility will only be scrutinized in this audit if DMA finds the supervising physician ineligible in the sample of 100 physicians outlined above.

But it is still essential that PAs and NPs return the requested paperwork within the 30-day timeframe. Please watch for this letter from DMA and handle immediately upon receipt.

Our goal is to inform you as early as possible when issues like this arise.  Please continue to watch the NCMS Bulletin and website for updates.


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