RD468 - Report on Audits of Home- and Community-Based Services - December 1, 2015


Executive Summary:
Home and Community Based Services (HCBS) are provided to individuals enrolled in Medicaid who meet criteria for admission to a nursing facility (NF) or Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/ID) but choose to receive services in a less restrictive and less costly community setting via 1915(c) waiver authority granted by the Centers for Medicare and Medicaid Services (CMS). The Department of Medical Assistance Services (DMAS) operates six HCBS Waivers including the Technology Assisted, Individual and Family Developmental Disability Support (DD), Elderly or Disabled with Consumer Direction (EDCD), Intellectual Disabilities (ID), Day Support (DS), and Alzheimer’s Assisted Living waivers.

Audits are conducted by internal DMAS Program Integrity staff from the Provider Review Unit as well as by a contractor, Myers & Stauffer (MSLC.) Audits are conducted to: 1) assure that Medicaid payments are made for covered services that were actually provided and properly billed and documented; 2) calculate and initiate recovery of overpayment; 3) educate providers on appropriate billing procedures; 4) identify potentially fraudulent or abusive billing practices and refer fraudulent and abusive cases to other agencies; and 5) recommend policy changes to prevent waste, fraud and abuse.

Pursuant to budget language, DMAS worked with providers to establish an advisory group of HCBS providers and held meetings in 2011, 2012, 2013 and 2014. Details on the activities of this workgroup in prior years can be found in DMAS’ 2011 report, "Evaluation of Effectiveness and Appropriateness of Review Methodology for Home and Community Based Services," 2012 "Report of the Activities of the DMAS Advisory Group on Audit Methodology for Home- and Community-Based Services," and the 2013 and 2014 reports titled "Report on Audits of Home- and Community-Based Services." For this reporting period there were no revisions made to the methodology for home- and community-based utilization and review audits; however, below is a summary of audit and appeal activity.