OIG audits managed care claims for durable medical equipment

The OIG conducted an audit of Medicaid claims submitted by managed care organization Cook Children’s Home Health from September 1, 2018 through August 31, 2020. The provider was reimbursed $13.6 million for durable medical equipment and supplies distributed to more than 8,000 Medicaid clients. The audit objective was to determine if documentation existed supporting the authorization and delivery of durable medical equipment and supplies and that all claims were completed in accordance with applicable state laws, rules and guidelines.

The OIG determined that Cook Children’s Home Health had processes and controls to ensure most required documentation was complete and met requirements to support the authorization of claims including prior authorization when required, documentation of visiting a physician within six months prior to the start of service and that all of the reviewed claims were for clients that were not residents of a hospital or a facility at the time of delivery. Cook Children’s Home Health also ensured that no prescribing physicians were listed in the United States Department of Health and Human Services Office of Inspector General exclusions database.

Out of 90 durable medical equipment and supplies claims selected for review by the OIG, three were found to not consistently comply with requirements for documentation and delivery.  Two claims did not include a signature from the client or caregiver on documents confirming receipt of deliveries made by Cook Children’s Home Health. One claim stated a quantity on the delivery documentation that was greater than the quantity ordered and authorized. Additional reviews discovered claims to and payments from Medicaid for more items than were authorized.

As a result, Cook Children’s Home Health should return $3,429 for overpayment or unsupported claims to the State of Texas. To read the full audit, please visit the OIG website.