Dear Mr. Waguespack:
The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2025 regarding a reportable audit finding related to Inadequate Controls over Waiver and Support Coordination Service Providers. LDH ap...
Dear Mr. Waguespack:
The Louisiana Department of Health (LDH) acknowledges receipt of correspondence from the Louisiana Legislative Auditor (LLA) dated February 7, 2025 regarding a reportable audit finding related to Inadequate Controls over Waiver and Support Coordination Service Providers. LDH appreciates the opportunity to provide this response to your office’s findings.
Finding: Inadequate Controls over Waiver and Support Coordination Service Providers
Recommendation: LDH should ensure all departmental policies for waiver and support coordination services are enforced, including documentation to support claims and evidence that deviations from the approved POC meet the needs of the recipient. LDH should consider additional provider training regarding documentation requirements.
LDH Response: The LDH through the Office for Citizens with Developmental Disabilities (OCDD) concur in part with the finding and recommendation set forth by the LLA.
LDH/OCDD does not concur with three errors LLA noted in the determination of inadequate controls over waiver and support coordination providers and have concerns with LLA’s overreliance on documentation in determining control adequacy.
Under §1915(c) of the Social Security Act and 42 CFR §441.302, the approval of an HCBS waiver requires that CMS determines the state has made satisfactory assurances concerning the protection of participant health and welfare, financial accountability, and other elements of waiver operations. Renewal of an existing waiver is contingent upon review by CMS and a finding by CMS the assurances have been met. By completing the HCBS waiver application, the state specifies how it has designed the waiver’s critical processes, structures, and operational features in order to meet these assurances.
Despite highlighting CMS approved controls and assurances, as well as LDH policy allowances, LLA continues to overlook other control mechanisms in place and rely solely on reconciling documentation to determine control adequacy.
1. “For 121 claims for 9 recipients, the waiver services provider did not provide documentation substantiating the reason for departures from the approved POC.”
There is no error because there was no departure from the plan of care. The nine (9) recipients referenced herein received the individual and family support (IFS) service(s) as outlined in the plan of care. The confusion here seems to stem from the structure of our IFS service. As approved in our 1915(c) waiver, IFS can be provided on a 1:1 basis or a shared basis (i.e. one direct support worker providing IFS to two waiver recipients). There is no difference in the service definition for 1:1 and shared IFS, nor a reduction in the scope or intensity of care. In other words, it is the same service.
It appears LLA has based its determination of departures from the comprehensive plan of care (CPOC) on the typical weekly schedule portion of CPOC. The typical weekly schedule serves as a map to determine the amount of supports needed, but it does not prohibit a recipient from altering the amount and type of IFS hours utilized within a day, week or month, so long as the recipient does not exceed the budgeted hours for the quarter. Understanding the dynamic nature of individuals’ lives, LDH/OCDD’s expectation is that people operate within their allocated budget or budget hours for the quarter, not the typical weekly schedule.
Health and safety is assured through OCDD’s Support Coordination Monitoring (Policy 604) process. The Support Coordination Monitoring Process evaluates if waiver participants receive the supports and services necessary to meet their needs (health and safety) and achieve their personal goals. Support Coordination Monitoring provides required evidence to the Centers for Medicare and Medicaid Services that the agencies are operating in accordance with applicable federal regulations/policies. For this monitoring process a composite sample that includes individuals served by all SC agencies are reviewed.
The components of the monitoring process include an Agency Review, Record Review, Participant Interview, and Support Coordination Interviews. The process in place is included in our 1915 c waiver applications and has been approved by CMS.
2. “For 50 claims for 3 recipients, the waiver services provider billed the claim at the incorrect rate.”
There was no error since the waiver provider billed the appropriate rate for the procedure code and modifier submitted on the claim. Furthermore, there are adequate controls in place by way of max allowed rate coding which prohibits a provider from billing above the maximum-allowed rate for the procedure code and applicable modifier.
Based on a review of the available data, it appears LLA has based its determination of improper rate on an individual 1:1 IFS rate. For the instances where the LLA noted the improper rate was paid, the procedure code and modifier identified was for a shared IFS service, which was the service the provider delivered. The rate billed aligned with the shared IFS rate.
3. “For 4 claims for 1 recipient, the waiver services provider inappropriately billed for services that overlapped with non-waiver institutional services.”
While the claim was paid, the example provided was not an error, as LDH’s established controls identified and addressed the overlap in billing.
LDH allows the delivery of direct care services by an in-home provider prior to the time of admission and after the time of discharge. The claim identified with date of service April 25, 2024 was the date of admission and the claim, with date of service (DOS) April 27, 2024, was the date of discharge. The agency billed Gainwell for the DOS for April 26, 2024 and Gainwell reimbursed the agency for that DOS. However, LDH has mechanisms in where claims paid but should have been denied cause future units to be blocked once the system recognizes the participant was inpatient during the date of the claim. SRI notifies the provider of the block (on the LaSRS® Blocked Report) and of their need to reimburse Gainwell, if the claim has already been billed and paid. Once they have repaid the blocked units at Gainwell, they will have enough units available to bill for the claims at the end of the prior authorization (PA).
This logic (or “block”) was implemented when the inpatient stay was billed and sent to our data contractor, SRI. SRI reduced the total amount released on this PA and the provider is currently being denied for later dates of service under this PA and will not be able to be reimbursed for the dates of service until they pay back the claims for April 26, 2024.
LDH/OCDD concurs with LLA’s error finding of inadequate documentation on 383 claims for 13 recipients.
Included in OCDD’s response to the last audit, OCDD developed a corrective action plan which consisted of the following elements:
• Develop/Finalize a standardize note to be utilized by all personal care type providers. The standardized note is developed. Starting February 2025, providers are required to begin using the note or electronic alternative/equivalent.
• Training/Implementation of standard progress note. Training is underway and scheduled to be completed by end of January 2025.
• Develop/Implement a monitoring process to review provider records/notes. Planned Implementation of monitoring process is July 2025.
LDH concurs with LLA’s recommendation regarding policy enforcement and additional support coordination (SC) training.
Corrective Action Plan: LDH developed the action steps below to address the need for SC documentation training and provide additional oversight for policy enforcement.
1. OCDD will revise the SC policies/procedures and interpretive guidelines to address findings from monitoring, including SC documentation requirements by February 2025.
2. OCDD will circulate revised policies/procedures and interpretive guidelines to LGEs and SCAs to provide feedback/recommendations by March 2025.
3. Finalize the policies/procedures and interpretive guidelines by May 2025.
4. Provide statewide training regarding policies/procedures in June 2025.
5. Implement revised policies/procedures and interpretive guidelines in July 2025.
6. Measure effectiveness by comparing results of monitoring post-revised guidelines with monitoring that occurred prior to the changes in December 2025.
Bernard Brown, Deputy Assistant Secretary, OCDD is responsible for the execution and implementation of this corrective action.
You may contact Bernard Brown, OCDD Deputy Assistant Secretary, at (225) 342-8807, or via email at Bernard.Brown@la.gov with any questions about this matter.