Improper Billing of Services Within the Medicaid Behavioral Health Program
Learn how the AI-generated research projects were createdOverall Conclusion
All issues identified in this report exist because the MCOs, Magellan, and LDH have not established sufficient edit checks to ensure claims and encounters that do not comply with the fee schedule are denied. LDH states that post-pay reviews and other analytics are in place, but the audit found substantial improper payments indicating a need for stronger pre-payment edit checks and data validation.
Source Document
Audit Scope
This audit examined the Louisiana Department of Health (LDH), the five Medicaid managed care organizations operating under the Healthy Louisiana program (AmeriHealth Caritas Louisiana, Inc.; Aetna Better Health, Inc.; Healthy Blue; Louisiana Healthcare Connections, Inc.; and UnitedHealthcare Community Plan of Louisiana, Inc.), and Magellan Health Services (administering behavioral health services for the Coordinated System of Care). It evaluated whether behavioral health providers’ claims were billed in accordance with LDH’s fee schedule and related policies, and whether the MCOs, Magellan, and LDH had appropriate edit checks to deny improper encounters and claims. The analysis covered encounters and payments from December 2015 through June 2019, focusing on the specialized behavioral health procedures, modifiers, and data accuracy used to determine encounter data integrity and payment accuracy. The audit acknowledged that the scope was less than Government Auditing Standards requirements and relied on LDH, MCOs, and Magellan data and controls; it includes the consideration of how data are used to set PMPM rates, and references prior related findings (notably the May 2019 report on NPI inclusion).
Key Findings Summary
The MCOs, Magellan, and LDH have not established sufficient edit checks to ensure behavioral health services are properly billed.
Approximately $47.5 million in encounters and claims (December 2015 through June 2019) were paid by LDH, the MCOs, and Magellan despite not complying with the LDH fee schedule.
Of this amount, $38,533,711 was paid for 646,746 encounters/claims with incorrect procedure and modifier codes.
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AI-Assisted
AI Scope Summary
To assess whether LDH, the five MCOs, and Magellan have adequate edit checks and controls to ensure behavioral health claims are billed and paid in accordance with LDH’s fee schedule, and to quantify and recommend remedial actions for improper payments identified from December 2015 through June 2019.
AI-Generated Insight
The Medicaid Behavioral Health audit in Louisiana reveals critical gaps in pre- and post-payment controls across LDH, MCOs, and Magellan. Despite a shift to a risk-based managed care model, the absence of robust edit checks for procedure and modifier codes led to nearly $47.5 million in noncompliant payments from 2015 to 2019. The report highlights the importance of enforceable data analytics, consistent application of the fee schedule, and stricter denial rules to protect program integrity and ensure proper reimbursement.