Evidence record
Improper Billing of Services Within the Medicaid Behavioral Health Program
- Jurisdiction
- Louisiana
- Publishing agency
- Louisiana Legislative Auditor
- Publication date
- September 4, 2019
- Source record
- Original document linked
Findings
6
Recommendations
2
Overall 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.
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).
Findings (6)
Each finding has a stable link.
- F-478
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.
- F-479
Of this amount, $38,533,711 was paid for 646,746 encounters/claims with incorrect procedure and modifier codes.
- F-480
647,910 encounters/claims totaling $9,044,773 were paid at rates higher than those listed in the LDH fee schedule.
- F-481
322 add-on behavioral health service claims totaling $7,800 were paid despite lacking a required primary service.
- F-477
The MCOs, Magellan, and LDH have not established sufficient edit checks to ensure behavioral health services are properly billed.
- F-482
The lack of robust edit checks allows mispayments and contributes to improper reimbursements.
Recommendations (2)
- R-434
LDH should ensure that the MCOs establish edit checks to ensure behavioral health claims are not paid unless they comply with the LDH fee schedule.
Related finding F-477 - R-435
LDH should establish edit checks to ensure that behavioral health encounters are accepted only when they comply with the LDH fee schedule.
Related finding F-477