Evidence record
Maine Made at Least $45.6 Million in Improper Fee-for-Service Medicaid Payments for Rehabilitative and Community Support Services Provided to Children Diagnosed With Autism
- Jurisdiction
- Maine
- Audit organization
- United States Department of Health and Human Services Office of Inspector General Office of Audit Services
- Publication date
- January 2026
- Source record
- Original document linked
Findings
7
Recommendations
4
Overall conclusion
For our audit period, the Maine Department of Health and Human Services’s FFS Medicaid payments for rehabilitative and community support services provided to children diagnosed with autism included improper and potentially improper payments. Improper payments totaled at least $45.6 million ($28.7 million Federal share) and potentially improper payments totaled about $22.4 million ($14.2 million Federal share). The issues stemmed from a lack of statewide postpayment reviews, insufficient guidance to providers on documentation, and inconsistent adherence to documentation requirements, which could affect the quality of care.
Scope
Audit covered Maine's fee-for-service Medicaid payments for rehabilitative and community support services for children under 21 with autism in calendar year 2023, including 165,309 claim lines across 11,777 enrollee-months; a stratified random sample of 100 enrollee-months was reviewed (payments totaling $779,742).
Findings (7)
Each finding has a stable link.
- F-1208
The State agency’s FFS Medicaid payments for RCS services provided to children diagnosed with autism did not fully comply with Federal and State requirements.
- F-1209
Comprehensive assessments were missing or did not include signatures of staff or parents/guardians.
- F-1210
Session notes did not meet documentation requirements.
- F-1211
The treatment plan did not include a parent or guardian signature or the plan was missing.
- F-1212
Documentation did not include provider credentials.
- F-1213
The State agency did not perform a statewide postpayment review of RCS payments and did not provide sufficient guidance to providers.
- F-1214
Potentially improper payments were identified for session notes that did not contain complete descriptions, included nontherapy time, or referred to unallowable recreational or academic activities.
Recommendations (4)
- R-1075
Refund $28,796,366 (Federal share) to the Federal Government for FFS Medicaid payments for RCS services that did not comply with Federal and State requirements.
Related finding F-1208 - R-1076
Exercise reasonable diligence to review and determine whether any of the estimated $14,163,521 (Federal share) in potentially improper payments for RCS services did not comply with Federal and State requirements and recover overpayments where applicable.
Related finding F-1214 - R-1077
Provide additional guidance to providers about how to document RCS services, including the information needed in session notes to support RCS services provided, billable RCS service time, and signature requirements.
Related finding F-1213 - R-1078
Periodically conduct a statewide postpayment review of Medicaid payments for RCS services, including reviewing medical records, and provide training to providers to address errors identified in postpayment reviews.
Related finding F-1213