Post Payment Review - Therapy Bills Greater than 12 Hours in a Single Day

Issue

The IDHS/DDD seeks to ensure that all billings for Physical Therapy, Occupational Therapy, Speech Therapy, Behavioral Intervention and Treatment, Group and Individual Therapies are accurate, documented and only provided by authorized licensed providers.

Basis for Review 

The Illinois Department of Human Services, Division of Developmental Disabilities (DDD) must conduct ongoing annual reviews of Medicaid Waiver programs per the approved Medicaid Waiver Application.

Method of Review

The DDD Bureau of Program Development & Medicaid Administration reviewed the bills from providers that provided for services more than 12 hours on a single day for the above services. This data is obtained from Mobius Report #M044K151 (Professional Provider with Paid Bills over 12 hours in a single day) dated 10/4/2015. The BPDMA staff notified those providers in writing requesting documentation to substantiate their billings.

Findings

Overall, there were 52 providers that had billed for greater than 12 hours in a single day. Out of 52 providers, 28 providers billed correctly, 23 providers had billing errors and 1 provider had 353 claims that were undocumented. Attached is a graph with each Service reviewed and totals for the substantiated and the unsubstantiated bills. There were 2,501 claims total with 1,994 of them billed correctly, with appropriate documentation, which is 80% accuracy. The majority of the unsubstantiated bills were time entry errors and incorrect dates for services provided entered in the ROCS system. Other errors resulted from billing agents entering the wrong Provider's Name or program code.

Actions Taken

• Providers were required to correct the unsubstantiated bills.
• The Division has recouped the payments that were unsubstantiated.
• Undocumented Data in Individual Therapy (58U) has been reported for investigation to The Department of Healthcare and Family Services' Office of Inspector General and to the Illinois State Police Medicaid Fraud Unit. No documentation has been received for 353 bills and all are billed by one Provider/Therapist.