Louisiana Department of Health failed to check Healthy Louisiana medical, dental providers

Trinity Velazquez
·6 min read

BATON ROUGE, La. (BRPROUD) – An audit found that the Louisiana Department of Health did not enroll and screen Healthy Louisiana health and dental managed care providers as federal rules require. They failed to do so for the sixth year in a row, according to the Louisiana Legislative Auditor’s Office.

The audit found that 28,733 providers were paid in fiscal year 2023. Of those, 8,183 (28%) were not enrolled and screened as required. This noncompliance hurts LDH’s ability to ensure provider information is accurate and in compliance with enrollment requirements.

LDH launched an enrollment portal in July 2021. However, it set a Dec. 31, 2022 deadline for provider enrollment. Some providers were ineligible for payments in fiscal year 2023 if they hadn’t enrolled before then. Management concurred with this finding and provided a corrective action plan.

LDH said the tentative completion date for enrolling the new providers is Sept. 30. After that, incoming providers will be invited to enroll bi-monthly.

LDH management partially agreed. They agreed with some other findings from the audit and provided action plans to fix them. They also mentioned system issues. These issues affect their ability to check Medicaid claims accurately.

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LDH did not follow NCCI rules for Medicaid fee claims for the third year in a row

Auditors found that LDH did not follow the rules for checking Medicaid claims. They should have used specific edits to ensure the claims were correct. Medically Unlikely Edits review claims for excessively billed units and set limits based on procedure codes. Procedure-to-procedure edits stop one specific procedure code from being billed with a different one on the same recipient on the same day by the same provider.

The audit said that LDH didn’t do this properly for all claims tied to medical equipment, hospital services and surgeries in the 2023 fiscal year. According to the audit, LDH paid $126,549 for claims that should have been denied because they billed too much (MUE) and paid $1,663 for claims that should have been denied because they billed procedures that shouldn’t be billed together (PTP).

Auditors said LDH needs to make sure they follow these rules for all claims in the future.

Management responded and partially concurred with the findings. LDH said they couldn’t do the checks earlier due to system issues. But, they later upgraded their system in April 2023 and asked for the claims to be rechecked. Some claims were recouped in December.

Audit finds mistakes about payments to medical vendors and federal spending

The department also had inadequate controls over annual financial reporting. This was the third year in a row.

The audit found mistakes in their reports regarding payments to medical vendors and federal spending. The audit suggests that LDH needs improved procedures to catch mistakes before submitting reports.

Management agreed and plans to enhance financial reporting controls.

Audit finds LDH violated federal rules for Medicaid and CHIP

The audit found that LDH accidentally reported the same $16.6 million spending twice. This was in different quarterly reports. It led to $14.9 million in questioned costs. The audit said LDH didn’t finish two of four quarterly checks to make sure their reports were correct. This caused them to miss a $1.7 million error.

Federal rules say LDH must report their spending accurately. The audit suggests they should improve their reporting. They should do all their checks to catch mistakes. LDH agreed with some of the findings. But, they disagreed that the checklist is “meant to show compliance with the federal reporting requirements.”

Management said the checklist is “used to document and track the receipt of source documents from other departments.” This lets the fiscal staff make work papers for the federal expenditure reports. They also said it doesn’t track the accuracy of the papers. They said the duplication was found in the single-state audit and would have been noted in the award reconciliation process.

LDH said it will keep building on the changes. The goal is to stop Medicaid spending mistakes from happening again.

Audit finds that LDH didn’t follow its policies about maternity care payments in 2023

Maternity kick payments are one-time reimbursements. They go to Managed Care Organizations for maternal care costs. The audit said LDH paid $887,955 without proof of a triggering event for Medicaid maternity kick payments. It also paid $79,182 without a triggering event for CHIP maternity kick payments.

For a maternity kick payment to be made, LDH policies need a triggering event to occur.

The audit recommends that LDH strengthen its policies. It should review all maternity kick payments and reclaim payments made without valid triggers.

LDH partly agreed with the findings. However, it disagreed about the number of unsupported payments. It noted that some events had triggers submitted after the audit period.

Audit finds LDH may have made mistakes in approving people for Medicaid and CHIP

For the fourth year in a row, the audit found that LDH lacked enough checks and balances. They need these to make sure they find out who qualifies for Medicaid and CHIP accurately. The audit said this could lead to problems like giving benefits to those who aren’t eligible.

The audit said these mistakes led to $20,843 in questioned costs for Medicaid and $15,249 for CHIP due to coverage errors.

The audit suggests that LDH ensures employees follow proper procedures for determining eligibility and renewals. They should do this to avoid these issues. In response, management said they did not agree with the errors. The errors were for not renewing both Medicaid and CHIP.

LDH said that during the public health emergency, they were using a March 25, 2020, waiver from CMS. This waiver allows them to be more flexible with the deadlines for renewing Medicaid benefits.

“LDH used the flexibility to suspend processing of standard renewals,” LDH said.

LDH made a corrective action plan to make sure case files show how eligibility was determined.

Audit finds LDH had inadequate controls over billing for behavioral health services

For the fifth year in a row, LDH, the managed care organizations, and Magellan Health Services lacked enough controls. These controls ensured that Medicaid and CHIP were billed correctly and denied improper encounters.

Auditors said they found $16 million in charges for services between July 1, 2022, and June 30, 2023. The MCOs and Magellan paid the charges. However, the services do not seem to meet LDH’s coding rules or approved fees.

The audit said that providers were paid $11,544,123 for 158,173 encounters. The encounters were billed using the wrong procedure and modifier codes. LDH’s fee schedule lists service procedure codes. It also lists the billing rates for each. Some services require procedure codes to have modifier codes. These codes show information like the recipient’s age, where the procedure was done, the performer’s education and their license.

The audit also said providers were paid $4,459,886 more than shown on the approved fee schedules for 59,902 encounters for behavioral health services.

“The approved fee schedules outline different rates depending on the procedure code and modifier codes. The MCOs can optionally pay more than the minimum LDH fee schedule. However, LDH does not currently maintain a list of these providers and therefore cannot determine if an encounter paid at an excessive rate was improperly billed,” the audit said.

Auditors recommended that LDH management ensure that agency personnel watch the EQR contract. They should also ensure that proper validations are done. This will ensure encounters are coded.

LDH pointed to ongoing progress on the issue and said they concur with the findings and outlined a plan to reduce problems further.

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