LDH Failed to Monitor $150 Million in Medicaid Claims to Determine if Services Provided, Payments Made Were Proper

A review of the Louisiana Department of Health’s (LDH) monitoring process for Medicaid T1015 claims paid to the state’s rural health clinics and federally-qualified health centers found that LDH staff failed to monitor these claims since the implementation of managed care in 2012, the Legislative Auditor said in a report released today.

The rural health clinics and federally-qualified health centers were set up to address concerns about adequate access to primary health care providers who serve Medicaid beneficiaries in rural and underserved areas. Covered health care services are reimbursed using the all-inclusive procedure code T1015 with a set negotiated rate.

To earn this T1015 rate, the provider must indicate the specific services provided by entering the individual procedure code and description, and a no charge or usual/customary charge for each service on subsequent claims lines. These subsequent lines are referred to as detail lines. The detail lines document the actual services performed.

Auditors with the Medicaid Audit Unit found that, between February 2012 and December 2016, LDH staff did not monitor the T1015 claims paid by the managed care organizations that provide health plans for the Medicaid program, the state auditor said.

Of the $348,093,877 paid by the managed care plans for T1015 claims, detail lines were missing for $150,196,886, or 43 percent. Without this claim detail, LDH could not ensure that appropriate services were provided or proper claim amounts were paid.

Without the required claim detail, the audit report said, claims could have been “unbundled,” meaning services were paid for separately rather than together at previously agreed-upon rates. There is also a risk that the claims filed were for non-covered services, which could mean the managed care plans made improper payments.

In addition, future payment rates could be affected if claims submissions that violated LDH policy are used as experience data. Managed care health plan claims submissions are used by an LDH contractor to set premium rates.