PURPOSE
The Illinois Department of Human Services/Division of Developmental Disabilities seeks to ensure that all billings for Waiver Services are accurate, are for the correct dates of service, and are properly documented in an audit trail. The Division also must ensure that 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 07/01/2020).
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:
- Residential attendance records that are completed daily on-site and specify whether or not the individual was present or, if absent, identify the type of bed hold.
- Day services 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 that other waiver services (such as therapy, counseling, etc.) are being delivered and paid.
- For services billed and paid on an hourly basis other than day program (ISSA, self-direction assistance, 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 Medicaid Administration Unit reviewed billings that were selected via a statistically valid random sample of individuals who received waiver services provided between December 16, 2019 and December 31, 2019, 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= 300 and Children's Residential Waiver= 152. Division 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 that supports 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 that 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 Services (CDS), Self-Direction Assistance (SDA), Personal Support, Nursing Support and Behavior Services. There were 11,215 total claims involved in this review covering all three Waivers, and of those claims, 11,185 were found to be compliant. The Division found 30 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 Waivers 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) |
95 |
180 |
2700 |
2695 |
5 |
5 |
| D2 |
Children's Group Home (17D) |
10 |
151 |
2118 |
2118 |
0 |
0 |
| D0 |
Occupational Therapy (52O) |
1 |
2 |
3 |
3 |
0 |
0 |
| D0 |
Community Living Facility (67D) |
2 |
3 |
41 |
41 |
0 |
0 |
| D0 |
CDS (31U) + Additional Staff Support (53D) |
97 |
224 |
1496 |
1483 |
13 |
13 |
| D0 |
Supported Employment (36U, 39U, 39G) |
15 |
18 |
84 |
82 |
2 |
2 |
| D0 & D1 |
SDA (55A) |
58 |
275 |
544 |
543 |
1 |
1 |
| D0 & D1 |
Personal Support (55D) |
15 |
414 |
3591 |
3591 |
0 |
0 |
| D0, D1 & D2 |
Behavior Services (56U,57U,57G,58U,58G) |
48 |
193 |
638 |
629 |
9 |
9 |
|
Totals |
* |
** |
11215 |
11185 |
30 |
30 |
*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 |
Total Individuals in Sample |
Total Number of Claims Involved |
Compliant |
Non-Compliant |
Corrected |
| D0 |
CILA (60D) + Additional Staff Support (53R) |
95 |
180 |
2700 |
2695 |
5 |
5 |
| D0 |
Community Living Facility (67D) |
2 |
3 |
41 |
41 |
0 |
0 |
| D0 |
CDS (31U) + Additional Staff Support (53D) |
97 |
224 |
1496 |
1483 |
13 |
13 |
| D0 |
Supported Employment (36U, 39U, 39G) |
15 |
18 |
84 |
82 |
2 |
2 |
| D0 |
SDA (55A) |
44 |
94 |
185 |
185 |
0 |
0 |
| D0 |
Occupational Therapy (52O) |
1 |
2 |
3 |
3 |
0 |
0 |
| D0 |
Personal Support (55D) |
7 |
149 |
1560 |
1560 |
0 |
0 |
| D0 |
Behavior Services (56U,57U,57G,58U,58G) |
40 |
80 |
283 |
279 |
4 |
4 |
|
Totals |
* |
** |
6352 |
6328 |
24 |
24 |
| 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) |
42 |
181 |
359 |
358 |
1 |
1 |
| D1 |
Personal Support (55D) |
13 |
265 |
2031 |
2031 |
0 |
0 |
| D1 |
Behavior Services (56U,57U,57G,58U,58G) |
9 |
22 |
62 |
57 |
5 |
5 |
|
Totals |
* |
** |
2452 |
2446 |
6 |
6 |
| Children's Residential Waiver Code |
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) |
10 |
151 |
2118 |
2118 |
0 |
0 |
| D2 |
Behavior Services (56U,57U,57G,58U,58G) |
7 |
91 |
293 |
293 |
0 |
0 |
|
Totals |
* |
** |
2411 |
2411 |
0 |
0 |
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 10 providers submit corrective action plans. Some of the issues found during the review that caused a provider to be found non-compliant were insufficient audit trail documentation, incomplete time sheets and billings entered in error.
