Attestation Report of the Nebraska Department of Health and Human Services Medicaid Aged and Disabled Waiver Payments
Learn how the AI-generated research projects were createdOverall Conclusion
The audit identified significant deficiencies in internal controls over AD Waiver payments, EVV verification, and related processes, resulting in observable overpayments and the risk of continued improper payments. The Department has implemented some corrective controls (e.g., NFOCUS validation for over-24-hour visits) but further action and sustained monitoring are required to ensure payment integrity going forward.
Audit Scope
Calendar year 2025 AD Waiver payments; testing of 47 participants across multiple providers; evaluation of EVV verification, service authorizations, eligibility determinations, and provider practices; identification of overpayments and control deficiencies; assessment of program integrity improvements implemented by the Department.
Key Findings Summary
Significant deficiencies in internal controls over Medicaid Aged and Disabled (AD) Waiver payments, EVV verification, service authorizations, eligibility determinations, and agency practices, leading to material overpayments and risk of improper payments.
Total overpayments identified during testing amounted to $181,199.
Multiple categories of payment deficiencies were observed, including: (a) Services billed for more than 24 hours per day; (b) outside employment overlapping with AD Waiver services; (c) billing times changed to outside the EVV verified times; (d) billing more hours than authorized under service authorizations; (e) duplicate service billings; (f) providers ov…
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AI-Assisted
AI Scope Summary
This audit aimed to evaluate the Nebraska DHHS Medicaid Aged and Disabled Waiver payments for 2025, focusing on the accuracy and propriety of payments, EVV verification, service authorizations, participant eligibility, and provider oversight. The testing identified multiple control deficiencies and $181,199 in overpayments across 47 participants, underscoring the need for stronger EVV enforcement, clearer service authorizations, improved case management, and agency governance to prevent future improper payments.
AI-Generated Insight
The findings reveal systemic weaknesses in verification, timekeeping, and governance around AD Waiver payments, with notable risks arising from outside employment, agency billing practices, and insufficient case coordination. Strengthening automated EVV controls, payer edits, and oversight, paired with stronger agency reviews and timely recovery of overpayments, will substantially reduce the risk of future improper payments.
Audit Objectives
No specific objectives documented for this audit
Audit Findings (5)
Significant deficiencies in internal controls over Medicaid Aged and Disabled (AD) Waiver payments, EVV verification, service authorizations, eligibility determinations, and agency practices, leading to material overpayments and risk of improper payments.
Total overpayments identified during testing amounted to $181,199.
Multiple categories of payment deficiencies were observed, including: (a) Services billed for more than 24 hours per day; (b) outside employment overlapping with AD Waiver services; (c) billing times changed to outside the EVV verified times; (d) billing more hours than authorized under service authorizations; (e) duplicate service billings; (f) providers overlapping hours across participants; (g) incorrect eligibility determinations; (h) EVV verification issues (GPS/IVR noncompliance, missing/incorrect signatures); (i) inadequate documentation of service task completion; (j) misuse of agency status to obtain higher rates; (k) provider signatures not captured on EVV forms.
Observations of system and process weaknesses included: lack of EVV controls to prevent 24-hour billing, insufficient monitoring of outside employment, misalignment between SNA tasks and hours billed, and insufficient coordination with case management for participant placement and provider oversight.
There were indications of potential data integrity concerns and noncompliance with Title 480 Nebraska Administrative Code (NAC) provisions and 1915(c) waivers, affecting payment accuracy and program integrity.
Recommendations (9)
Ensure payments are allowable, adequately supported, and in accordance with State and Federal regulations; conduct periodic post-payment reviews to validate allowance and support.
Implement EVV system edits and controls to prevent billable start times from being extended beyond actual times, prevent exceeding weekly service authorizations, and prevent duplicate billings.
Create and collect overpayments rather than requiring providers to adjust claims, and ensure overpayments are promptly detected and recovered.
Improve service task assignment and documentation in the Service Needs Assessment (SNA); educate providers on task completion and not over-record tasks.
Ensure services and their authorizations align with participant eligibility and care needs; strengthen quarterly service utilization monitoring and monthly face-to-face or equivalent monitoring by Service Coordinators.
Review and monitor agencies, especially those serving a single participant, to ensure rates are justified, customary, and not inflated by agency status; document rate negotiations.
Improve EVV form signing by capturing caregiver and participant signatures as required, or authorized representatives to sign where appropriate; ensure signatures are complete and verifiable.
Clarify service authorizations language to reflect flexible, client-centered care within annual/weekly limits; escalate any identified misbillings to program integrity for investigation.
Strengthen eligibility determinations to include all relevant income sources (e.g., Social Security) and ensure adherence to 100% FPL or Medically Needy thresholds; enforce timely revalidation and oversight.