The findings can be grouped into several areas as shown below. The responses are included below each grouping. Each response is included in each category.
1. Licensing
a. “Licensing for providers of behavioral healthcare services and home and community-based services to members with developmenta...
The findings can be grouped into several areas as shown below. The responses are included below each grouping. Each response is included in each category.
1. Licensing
a. “Licensing for providers of behavioral healthcare services and home and community-based services to members with developmental disabilities are, by statute, the responsibility of the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH). BHDDH, in conjunction with evaluations of provider health and safety standards, relicenses providers biennially. Inconsistent with most Medicaid providers, EOHHS, as the Medicaid agency, does not receive annual licensing data from BHDDH resulting in a weakness in control for this segment of providers.”
b. “Licensing for providers of residential services (inclusive of psychiatric services) to children in the State’s custody is, by statute, the responsibility of the Department of Children, Youth, and Families (DCYF). DCYF, in conjunction with evaluations of provider health and safety standards, relicenses providers annually. Inconsistent with most Medicaid providers, EOHHS, as the Medicaid agency, does not receive annual licensing data from DCYF resulting in a weakness in control for this segment of providers.
c. 4 out of 60 providers sampled noted instances where providers remained active during fiscal 2024 after provider licenses had expired, evidencing a deficiency in internal control relating to timely provider deactivation if provider licensure is not evidenced. No claims were paid to these providers thus noncompliance was not noted.”
EOHHS’ Division of Medicaid Compliance is actively working with BHDDH, DCYF, and RIDOH to address the licensing concerns by strengthening the communication of end dates between each agency’s licensing division and Medicaid’s Division of Medicaid Compliance.
Anticipated Completion Date: Ongoing. Anticipated June 2025.
Contact Persons: Emily Tumber, Implementation Director of Policy and Programs, Executive Office of Health and Human Services
emily.tumber@ohhs.ri.gov
Nicholas James, Implementation Director of Policy and Programs, Executive Office of Health and Human Services
nicholas.james@ohhs.ri.gov
2. Systems
a. “Encounter data submitted by managed care organizations is not currently validated for provider enrollment upon acceptance. This deficiency in internal controls over provider eligibility prevents the detection of claiming submitted by unenrolled providers. Our testing noted 4 managed care providers that were not enrolled in the Medicaid Program as required by federal regulations resulting in noncompliance with provider eligibility requirements (questioned costs - $3,371). All 4 providers were out-of-state providers required to be enrolled under federal regulations based on the volume of services billed to RI Medicaid. Implementing this additional edit when processing encounter data would improve controls over compliance.
b. For claims representing care furnished to a beneficiary by an out-of-state furnishing provider, the SMA may pay a claim, in limited circumstances, to a furnishing provider that is not enrolled in the reimbursing state’s Medicaid plan. In these circumstances, the State is required to meet several requirements including verification that the provider is enrolled in good standing in Medicare or another state’s Medicaid program. The State is not currently performing such validation for out-of-state providers with limited claiming.
c. The State did not have documentation supporting review of the SSA Death Master file for 19 out of the 60 providers we tested.
a. EOHHS conducted research on these cases and completed a system upgrade to remedy the issue on 5/1/2024.
b. EOHHS conducted research on these cases and completed a system upgrade to remedy the issue on 5/1/2024.
c. EOHHS implemented new Provider Screening Tool in February 2025 which will provide dated documentation following the automated search for various screening requirements, including Death Master File. This documentation will be uploaded to the provider file. This will eliminate the manual process of searching for providers individually through the Death Master File and relying on an individual recording the date.
Anticipated Completion Date: Ongoing
Contact Person: Kimberly Tebow, Senior Medical Care Specialist, Executive Office of Health and Human Services
kimberly.tebow@ohhs.ri.gov
3. Provider Surveys
a. Federal regulations require the Medicaid agency to execute provider agreements with nursing facility providers and intermediate care facilities for individuals with intellectual disabilities (ICF/IID) upon receiving notification from the State survey and certification unit that the provider has been certified in substantial compliance with federal health and safety regulations. The State Medicaid agency lacked documentation of a finalized provider agreements and approval letters to providers in 6 out of 18 providers reviewed. In respect to the State’s only ICF/IID facility, the State Medicaid agency was not monitoring the RI Department of Health’s (RIDOH) certification process and had no documentation from RIDOH regarding the facility’s health and safety certification. All providers were recertified by RIDOH and compliant with program health and safety requirements.
EOHHS/Medicaid implemented tracking protocol for all surveys received by the RIDOH to ensure completeness and timely response. Revisions to the internal standard operating procedure for the review and approval of these surveys are under review. This was completed on February 1, 2024. Regarding the monitoring of RIDOH’s certification process, EOHHS will collaboratively work with RIDOH to implement a monitoring program.
Anticipated Completion Date: June 2026 for the monitoring program.
Contact Person: Patricia Arruda, Chief of Strategic Planning, Monitoring & Evaluation, Executive Office of Health and Human Services
patricia.arruda@ohhs.ri.gov