Independent Auditor’s Report on Compliance with Requirements of the Medicaid Program
Learn how the AI-generated research projects were createdOverall Conclusion
Disclaimer of Opinion due to limitation on the scope of the examination; the scope was not sufficient to express an opinion on CarePlus’ compliance with the specified Medicaid requirements for the period January 1, 2021 through December 31, 2023.
Audit Scope
Period January 1, 2021 through December 31, 2023; testing select home health and waiver services as described in the engagement.
Key Findings Summary
One aide matched Office of Inspector General exclusion database and the Department's exclusion/suspension list, but identity could not be confirmed due to undelivered information request
Material noncompliance with service days when the recipient was inpatient in a hospital, lack of service documentation for nursing services, lack of plans of care or plans of care not signed by physician for nursing services, and lack of first aid certification for personal care aide services; provider failed to comply with electronic health record system re…
Implied that all nursing licenses were current and valid; no licensure finding
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AI-Assisted
AI Scope Summary
This compliance examination assessed CarePlus Home Healthcare LLC's adherence to Medicaid requirements for select home health and waiver services for 2021–2023, focusing on provider qualifications, service documentation, and authorization to provide services. The audit identified material noncompliance and improper payments, resulting in a disclaimer of opinion, with recommended improvements to provider qualification checks, documentation accuracy, and signed plans of care to strengthen future audits.
AI-Generated Insight
The audit found material noncompliance in several areas including inpatient billing during hospital stays, insufficient documentation, missing plans of care, and missing first aid certification for aides, leading to improper payments totaling $11.21k. The report notes limitation on the scope and lack of an official response. Recommendations focus on strengthening provider qualifications, documentation, authorization processes, and potential use of Department technical assistance. The findings suggest risk of recoupment and the need for stronger internal controls at CarePlus.
Audit Objectives
All instances in which a service was billed during a potential hospital inpatient stay
A specific date of service in which 10 services were billed for a recipient
All dates of service in which eight services were billed for the same recipient on the same day with the same units, procedure code, modifiers and paid amount
All instances in which 10 or more registered nursing (RN) assessments were billed for a recipient in a calendar year (CY)
All instances in which multiple nursing services were billed on a day for two recipients at the same address
A sample of waiver personal care aide services
A sample of state plan licensed practical nurse (LPN) services
Audit Findings (4)
One aide matched Office of Inspector General exclusion database and the Department's exclusion/suspension list, but identity could not be confirmed due to undelivered information request
Material noncompliance with service days when the recipient was inpatient in a hospital, lack of service documentation for nursing services, lack of plans of care or plans of care not signed by physician for nursing services, and lack of first aid certification for personal care aide services; provider failed to comply with electronic health record system review
Implied that all nursing licenses were current and valid; no licensure finding
There were improper Medicaid payments identified in the amount of $9,715.98, plus interest of $1,493.13, totaling $11,209.11
Recommendations (7)
CarePlus should review Ohio Medicaid rules and ensure all provider qualifications fully comply before rendering direct care services or participating in the Medicaid program
CarePlus should ensure first aid certificates contain information necessary to confirm validity and duration of the certification
CarePlus should seek technical assistance from the Department to determine if first aid certification is appropriate for aides rendering MyCare Ohio waiver services
CarePlus should develop and implement procedures to ensure that all service documentation and billing practices fully comply with Ohio Medicaid rules
CarePlus should implement a quality review process to ensure documentation is complete and accurate prior to submitting claims for reimbursement
CarePlus should develop and implement controls to ensure all services billed are authorized by a signed plan of care prior to submitting claims
CarePlus should ensure plans of care contain an authentic signature from the recipient’s treating physician or allowed practitioner