Medicaid Waiver Compliance Review – Review of all DDD Waivers for Claimed Waiver Services Billed July 16-31, 2017

PURPOSE

The Illinois Department of Human Services/Division of Developmental Disabilities seeks to ensure all billings for Waiver Services are accurate, are for the correct dates of service, and are properly documented with an audit trail. The Division also must ensure services provided are covered under the Waiver and services billed for are authorized in the individuals Person Centered Plan (PCP), or Individual Service Plan (ISP) prior to 07/01/2018.

BASIS FOR REVIEW

The IDHS/DDD must conduct ongoing annual reviews of Medicaid Waiver programs per the approved Medicaid Waiver Application. Per Article X, Section B, Subsection 3 of the DD Waiver Manual…The service provider is responsible for submitting complete and accurate billings and for maintaining appropriately detailed documentation and audit trail information. Service providers must maintain documentation on file for at least six years from the date of service to establish an audit trail. Audit trail documentation and notes are subject to review by state staff or their designees. Documentation includes:

  1. Residential attendance records which are completed daily on-site and specify whether or not the individual was present or, if absent, identify the type of bedhold.
  2. Day service attendance records completed daily on site and must include the number of hours each individual was actively involved in program activities during the day, start and end times, time out for lunch unless it is part of active programming, and any time spent not participating in program activities (such as a doctor's or therapist's appointment in the middle of the day). Day services cannot be billed at the same time other waiver services (such as therapy, counseling, etc.) are being delivered and paid.
  3. For services billed and paid on an hourly basis other than day program (ISSA, self direction assistance (or service facilitation prior to 7/01/18), behavior services, therapies and personal support), staff logs must include the number of hours and minutes provided and the date and time of services to each individual. Progress and other case or activity notes should also support the hours billed.

METHOD OF REVIEW

The Bureau of Program Development & Medicaid Administration (BPDMA) reviewed billings selected via a statistically valid random sample of individuals who received waiver services provided between July 16 and July 31, 2017, and later billed and then claimed. The sample was drawn using a Raosoft calculator with a 95% confidence level and a 5% margin of error. The total number in each Waiver sample is as follows: Adult Waiver = 378, Children's Support Waiver= 294 and Children's Residential Waiver= 140. BPDMA staff notified the selected providers in writing requesting documentation to substantiate their billings. The selected providers were asked to submit any and all audit trail documentation supporting their billings of Medicaid Waiver services. Examples of this required documentation were the individual's plan, time in and out sheets, progress notes, Individual Service and Support Advocacy (ISSA) notes, attendance records, nightly residential logs, schedules, any documents which contribute to an audit trail. DDD staff reviewed all documents submitted by the providers to determine the presence of an acceptable audit trail.

FINDINGS

The sample selected individuals who had billings from Community Integrated Living Arrangements (CILA), Children's Group Homes, Community Living Facilities, Hourly Intermittent CILA, Community Day Service, Service Facilitation, Personal Support, Nursing Support, and Behavior Services. There were 12,540 total claims involved in this review covering all three Waivers, and of those claims, 12,463 were found to be compliant. The Division found 77 claims to be non-compliant. These numbers are displayed in the "All Waiver Codes" table below, and then the numbers are broken down by each of the individual Waiver in separate tables: Adult Waiver Code (D0), Children's Support Waiver Code (D1) and Children's Residential Waiver Code (D2).

All Waiver Codes Program Name (Code) Total Providers in Sample Total Individuals in Sample Total Number of Claims Involved Compliant Non-Compliant Corrected
D0 CILA (60D) + Additional Staff Support (53R) 104 215 3296 3294 2 2
D0 CILA w/ At home Day Program (60C) 7 7 60 60 0 0
D2 Children's Group Home (17D) 13 138 2097 2092 5 5
D0 Community Living Facility (67D) 3 7 106 106 0 0
D0 Hourly Intermittent CILA (65H) 3 3 21 21 0 0
D0 Community Day Service (31A, 31U) + Additional Staff Support (53D) 106 282 2632 2583 49 49
D0 Supported Employment (36U, 39U, 39G) 17 21 198 198 0 0
D0 & D1 Service Facilitation (55A) 65 340 917 897 20 20
D0 & D1 Personal Support (55D) 21 363 3085 3085 0 0
D1 HBS, Temp. Assist. (53C) 1 1 16 16 0 0
D0, D1 & D2 Behavior Services (56U,57U,57G,58U,58G) 37 56 107 106 1 1
DO HBS, Overtime (55O) 1 2 4 4 0 0
DO HBS, Transportation (55T) 1 1 1 1 0 0
Totals * ** 12540 12463 77 77

*Total number of providers would not be accurate if summed as some providers provided more than one Waiver Service.

**Total number of individuals cannot be added to get to the number in the random sample due to an individual being enrolled in more than one program.

Adult Waiver Code Program Name (Code) Total Providers in Sample Total Individuals in Sample Total Number of Claims Involved Compliant Non-Compliant Corrected
D0 CILA (60D) + Additional Staff Support (53R) 104 215 3296 3294 2 2
D0 CILA w/ At home Day Program (60C) 7 7 60 60 0 0
D0 Community Living Facility (67D) 3 7 106 106 0 0
D0 Hourly Intermittent CILA (65H) 3 3 21 21 0 0
D0 Community Day Service (31A, 31U) + Additional Staff Support (53D) 106 282 2632 2583 49 49
D0 Supported Employment (36U, 39U, 39G) 17 21 198 198 0 0
D0 Service Facilitation (55A) 40 99 228 227 1 1
D0 Personal Support (55D) 16 115 1217 1217 0 0
D0 Behavior Services (56U,57U,57G,58U,58G) 20 25 58 58 0 0
DO HBS, Overtime (55O) 1 2 4 4 0 0
DO HBS, Transportation (55T) 1 1 1 1 0 0
Totals * ** 7821 7769 52 52
Children's Support Waiver Code Program Name (Code) Total Providers in Sample Total Individuals in Sample Total Number of Claims Involved Compliant Non-Compliant Corrected
D1 Service Facilitation (55A) 44 241 689 670 19 19
D1 Personal Support (55D) 11 248 1868 1868 0 0
D1 Behavior Services (56U,57U,57G,58U,58G) 8 8 13 13 0 0
D1 HBS, Temp. Assist. (53C) 1 1 16 16 0 0
Totals * ** 2586 2567 19 19
Children's Residential Waiver Code Program Name (Code) Total Providers in Sample Total Individuals in Sample Total Number of Claims Involved Compliant Non-Compliant Corrected
D2 Children's Group Home (17D) 13 138 2097 2092 5 5
D2 Behavior Services (56U,57U,57G,58U,58G) 11 23 36 35 1 1
Totals * * 2133 2127 6 6

Waiver Codes

D0 = Adult Waiver

D1 = Children's Support Waiver

D2 = Children's Residential Waiver

Below is a link to the DDD Waiver Manual which describes each Waiver in detail.

DDD Waiver Manual

ACTIONS TAKEN

Providers were asked to submit corrective action plans if the documentation they provided did not comply with the appropriate audit trail documentation. We had a total of 77 providers submit corrective action plans. Some of the issues found during the review causing a provider to be found non-compliant were insufficient audit trail documentation, incomplete time sheets and billings entered in error. The Division of Developmental Disabilities will post an Informational Bulletin explaining acceptable timesheets and time-in / time-out reporting for Developmental Training.