Follow-Up Assessment on a Previously Published Audit Report Managed Care Claims Submitted by Cook Children’s Home Health
Learn how the AI-generated research projects were createdOverall Conclusion
Based on our assessment, Cook Children’s Home Health did not fully resolve some reported audit issues and the agency must repay $1,064.92 to the state of Texas for overpayments identified during this assessment; two recommendations from the previous audit were reissued and modified as appropriate.
Source Document
Audit Scope
The follow-up assessment tested the resolution status of issues identified in the previously published audit report AUD-22-002 concerning Cook Children’s Home Health. Testing covered durable medical equipment and supplies claims paid to Cook Children’s Home Health, with payments evaluated for claims and related documentation for March 1, 2023, through February 29, 2024. The engagement was conducted from September 24, 2024, through January 8, 2025, including review of order forms, prior authorizations, delivery tickets, and delivery confirmations; data reliability was assessed by comparing encounter data to medical records and interviewing staff.
Key Findings Summary
Cook Children’s Home Health did not fully resolve some previously identified audit issues; two recommendations from the prior audit were reissued with modifications.
Overpayments totaling $1,064.92 were identified during this assessment and must be repaid to the state of Texas.
Issues identified include duplicate claims, incorrect/delivered quantities, and unauthorized items; testing of 7 of 19 members (36.8%) showed billing irregularities.
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AI-Assisted
AI Scope Summary
This audit follow-up builds on the objectives of assessing resolution status of prior audit findings, confirming the effectiveness of remediation controls, and identifying remaining risk areas (duplicate claims and misdelivered quantities). It sets the stage for future audits by emphasizing validation of delivery controls, enhanced duplicate detection, and timely recovery of overpayments.
AI-Generated Insight
This follow-up assessment confirms partial resolution of prior issues related to durable medical equipment and supplies claims. It highlights ongoing weaknesses in delivery quantity controls and duplicate-claim detection, which contributed to identified overpayments totaling $1,064.92. The findings underscore the need for strengthened processes, expanded testing, and timely repayment actions to prevent recurrence in future audits.
Audit Objectives
Determine the resolution status of the issues identified in the previously published audit report on Cook Children’s Home Health (AUD-22-002).
Test the effectiveness of management activities designed to remediate identified issues.
Audit Findings (5)
Cook Children’s Home Health did not fully resolve some previously identified audit issues; two recommendations from the prior audit were reissued with modifications.
Overpayments totaling $1,064.92 were identified during this assessment and must be repaid to the state of Texas.
Issues identified include duplicate claims, incorrect/delivered quantities, and unauthorized items; testing of 7 of 19 members (36.8%) showed billing irregularities.
Controls to match delivery order quantities with authorizations and to identify/reverse duplicate claims were implemented but not always effective; further evaluation of duplicate detection controls is required.
Specific repayments identified in prior recommendations include $2,523.50 (1b) and $905.82 (2b); plus note that the assessment identified overall overpayments of $1,064.92.
Recommendations (2)
Strengthen its controls to process deliveries as ordered and in authorized quantities.
Reevaluate whether its controls effectively identify and correct duplicate claims and deliveries.