Final Audit Report - ADV Counseling Services, LLC

  • Posted on - 02/1/2021

Table of Contents

  1. Executive Summary
  2. Background
  3. Audit Methodology
  4. Audit Findings
  5. Summary of Overpayments
  6. Recommendations
  7. ADV’s Response to the Draft Audit Report and MFD’s Comments

BY ELECTRONIC MAIL

Jaime (Kaplan) Epstein, LCSW
ADV Counseling Services, LLC
113 Mt. Vernon Ave.
Northfield, NJ 08225

 

RE: Final Audit Report: ADV Counseling Services, LLC

Dear Ms. Epstein:

As part of its oversight of the New Jersey Medicaid program (Medicaid), the Office of the State Comptroller, Medicaid Fraud Division (MFD) conducted an audit of Medicaid claims submitted by and paid to ADV Counseling Services, LLC (ADV), owned by Jaime (Kaplan) Epstein, LCSW (Licensed Clinical Social Worker) for the period from March 1, 2014 through February 15, 2019 (audit period). MFD hereby provides ADV with this Final Audit Report.

Executive Summary

MFD conducted an audit of Medicaid claims paid to ADV to determine whether ADV billed for intensive in-community mental-health rehabilitation and behavioral assistance services in accordance with applicable state and federal laws and regulations. Specifically, the audit sought to determine whether ADV correctly billed Healthcare Common Procedure Coding System (HCPCS) codes H0036 (intensive in-community services, face-to-face, per 15 minutes), H2014 (individual behavior assistance services, per 15 minutes), and H0018 (intensive in-community assessment), which are used to seek reimbursement for intensive in-community mental-health rehabilitation and behavioral assistance services. From its audit of 523 statistically selected claims totaling $95,061.09, MFD determined that 47 of the 523 claims, totaling $3,042.59 in reimbursement, failed to comply with state and federal regulations. The 47 failed claims contained a total of 52 exceptions, or reasons why such claim failed to comply with a requirement, as some claims failed for multiple reasons.   

Specifically, MFD found: a) 6 exceptions for ADV having failed to obtain criminal background checks for behavioral assistants (BAs) prior to such BAs providing services; b) 1 exception for ADV having failed to maintain proof of education for BAs; c) 9 exceptions for ADV having billed services to multiple recipients on the same date of service, at the same or overlapping times; d) 8 exceptions for ADV having billed for travel time in the calculation of face-to-face contact with a beneficiary; e) 7 exceptions for ADV having billed for claims where services were not documented with a progress note; f) 19 exceptions for ADV having billed for unsubstantiated services; and g) 2 exceptions for ADV having failed to comply with the minimum age requirement for its BAs.

To better understand the significance of the exceptions noted above, it would be helpful to discuss the qualification requirements that apply to ADV and other intensive in-community mental-health rehabilitation and behavioral assistance service providers. First, these providers must ensure that their BAs successfully completed criminal background checks and maintain a record showing the successful completion of these checks. This ensures that BAs who are providing one-on-one care for Medicaid beneficiaries, in this case, children/youth/young adults, do not have a criminal history, which increases the assurance that the BA will not compromise the safety and security of beneficiaries. Similarly, pursuant to another regulatory provision, providers must ensure that each BA possesses, at a minimum, a high school diploma or equivalent, and is at least 21 years of age or older. These requirements provide a level of assurance that these hands-on caregivers possess the academic proficiency to have completed high school education or an equivalent thereto and that they are socially responsible enough to work in a one-on-one setting with the beneficiary population. Finally, a regulatory provision requires providers to maintain proof that each BA possesses a valid driver’s license. This ensures that BAs, who often drive beneficiaries during the course of treatment, are duly licensed drivers. A provider that fails to meet one or more of these straightforward regulatory requirements may be retaining an unqualified BA and thereby potentially placing vulnerable beneficiaries into an unsafe position. Given the serious potential harm that can occur in these situations, any provider that violates any of these requirements must promptly and fully address, and fix the noted violation(s).    

In summary, the total 47 failed claims contained 52 different exceptions, as some claims failed for multiple reasons. For purposes of ascertaining a final recovery amount, MFD extrapolated the dollar error rate for these 47 failed claims to the total population of claims from which the sample claims were drawn, which in this case was 12,556 claims with a total payment amount of $2,326,583.07. After extrapolating the sample dollars in error over the entire universe, MFD calculated that ADV received an overpayment of $76,663.68.[1]

Background

The Division of Medical Assistance and Health Services (DMAHS), within the New Jersey Department of Human Services (DHS), administers New Jersey’s Medicaid program. Medicaid is a program through which individuals with disabilities and/or low incomes receive medical assistance. The Medicaid program provides intensive in-community mental-health rehabilitation and behavioral assistance services to improve or stabilize children and young adults’ level of functioning within the home and community. These services seek to prevent, decrease, or eliminate behaviors or conditions that may place the individual at an increased clinical risk or otherwise negatively affect a person’s ability to function. These services are provided within the context of an approved plan of care and are restorative or preventative in nature.

ADV, located in Northfield, New Jersey, has participated in the Medicaid program as an intensive in-community mental health rehabilitation and behavioral assistance services provider since June 1, 2008. ADV bills the Medicaid program for services under HCPCS codes H0036, H2014, and H0018. During the audit period, Jaime (Kaplan) Epstein, as owner of ADV, not only billed for services that she personally rendered, but also billed under the ADV provider number for services provided by 52 other behavioral healthcare professionals with whom she had contracted. Accordingly, references to ADV may include services performed by Jaime (Kaplan) Epstein or the other behavioral health professionals for whose services Jaime (Kaplan) Epstein billed under ADV’s provider number.

Objective

The objective of this audit was to evaluate claims billed by and paid to ADV to determine whether these claims were billed in accordance with applicable state and federal laws and regulations.

Scope

The audit period was March 1, 2014 through February 15, 2019. The audit was conducted under the authority of the Office of the State Comptroller as set forth in N.J.S.A.52:15C-23 and the Medicaid Program Integrity and Protection Act, N.J.S.A.30:4D-53 et seq.

Audit Methodology

MFD’s methodology consisted of the following:

  • Selecting a statistically valid sample of 70 service days representing 523 claims, totaling $95,061.09, from a population of 12,556 paid claims totaling $2,326,583.07, billed under HCPCS codes H0036, H2014, and H0018.
  • Reviewing records to determine whether ADV possessed documentation to support that it: rendered the services billed; obtained prior authorization for services; maintained progress notes that contained required information; conducted criminal background checks on BAs before such BAs performed services for which ADV billed; ensured that services were performed by BAs who had a current and valid driver’s license; ensured that BAs who performed services had the required level of education; and, obtained from a parent/guardian an attestation of services listed on the Service Delivery Encounter Documentation (SDED) forms.
  • Reviewing records for compliance with the requirements in N.J.A.C 10:49-9.8 (a), N.J.A.C. 10:49-9.8(b)(1), N.J.A.C. 10:77-4.9(e), N.J.A.C. 10:77-4.9(f), N.J.A.C. 10:77-4.9(g), N.J.A.C. 10:77-4.12(e)(6), N.J.A.C. 10:77-4.14(c)(1), N.J.A.C. 10:77-4.14(d)(2), N.J.A.C. 10:77-4.12(d)(3), -(5), N.J.A.C. 10:77-4.14(d)(1), N.J.A.C. 10:77-5.12(d)(3), -(5), and N.J.A.C. 10:77-5.12(e)(6).

Audit Findings

A. ADV Failed to Obtain Criminal Background Checks for Behavioral Assistants Prior to Rendering Services to Beneficiaries

Pursuant to state regulation, intensive in-community mental health rehabilitation and behavioral assistance services providers must ensure that successful background checks are performed on employees who have direct contact with or render behavioral assistance services to beneficiaries. State regulations further require providers to maintain evidence that a “recognized and reputable” entity successfully completes these criminal background checks.

MFD requested documentation to determine whether ADV maintained evidence of successfully completed criminal background checks for each BA prior to each BA having provided services to beneficiaries. MFD found that ADV permitted three BAs to provide behavioral assistance services to beneficiaries without having first obtained a criminal background check before these BAs provided services. Specifically, MFD found that ADV billed for behavioral assistance services for 6 of the 523 claims, totaling $468.00, without having first obtained criminal background checks for three BAs. In one instance, accounting for 1 of the 523 claims totaling $78.00, ADV obtained a criminal background check subsequent to the BA providing services. ADV billed and was paid for 1 sample claim for a date of service of March 2, 2016, but did not obtain a successfully completed background check until June 11, 2016, more than three months after the date of service. For the remaining two BAs, who accounted for 5 of the 523 claims, totaling $390.00, ADV failed to provide supporting documentation that it ever obtained criminal background checks. By failing to obtain successful criminal background checks before its employees provided services to Medicaid beneficiaries and, in other cases, for the entire audit period, ADV violated N.J.A.C. 10:77-4.9(g) and N.J.A.C. 10:77-4.14(d)(2).

Pursuant to N.J.A.C. 10:77-4.9(g), “[a]ll employees having direct contact with and/or rendering behavioral assistance services directly to the beneficiaries shall be required to successfully complete criminal background checks.”

Pursuant to N.J.A.C. 10:77-4.14(d)(2), the provider must maintain “[v]erified written documentation of successful completion of a criminal background check conducted by a recognized and reputable search organization for all staff having direct contact with children.”

 

B. ADV Failed to Maintain Proof of Education for Behavioral Assistants

To perform behavioral assistance services, a BA must have, at a minimum, a high school diploma or equivalent. ADV must maintain proof that each BA met this education requirement. MFD requested that ADV provide copies of high school diplomas or their equivalents for each BA to determine whether qualified individuals performed services and whether ADV maintained proper documentation showing that each BA satisfied this minimum education requirement. MFD found that ADV lacked the requisite documentation for one BA, who accounted for 1 of the 523 claims, totaling $68.25. For this claim, ADV violated N.J.A.C. 10:77-4.9(e) and N.J.A.C. 10:77-4.14(c)(1).

Pursuant to N.J.A.C. 10:77-4.9(e), “[a]ll direct care staff shall, at a minimum, have a high school diploma or equivalent, be 21 years old and have a minimum of one year relevant experience in a comparable environment and shall be supervised by appropriate clinical staff in accordance with this subchapter.”

Pursuant to N.J.A.C. 10:77-4.14(c)(1), the provider must maintain “[a] copy of the direct care staff person’s high school diploma or equivalent.”

 

C. ADV Billed for Services Provided to Multiple Beneficiaries at the Same or Overlapping Times

State Medicaid regulations regarding intensive in-community mental-health and behavioral assistance services require providers to maintain records for each encounter documenting the name and address of the beneficiary; the exact date, location and time of service; the type of service; and, the length of face-to-face contact time. Most of this information is documented on the SDED. This form, which must be signed and dated by the servicing provider who rendered the service and the beneficiary or their parent/legal guardian, must be completed for every service encounter between a provider and beneficiary.

MFD reviewed ADV’s records, including the SDED forms, to determine whether ADV sufficiently documented the services rendered. Specifically, MFD compared the encounter dates and times recorded on the SDED forms to determine if multiple claims overlapped in time. MFD found that for 9 of the 523 sample claims, totaling $883.00, ADV billed for services provided by the same servicing provider to multiple beneficiaries or by different servicing providers to the same beneficiary at the same or overlapping time(s). For example, one SDED form documented that an ADV servicing provider rendered services on October 27, 2017, from 3:30 PM to 8:30 PM. A second SDED form for that same date documented that the same ADV servicing provider provided services to a different Medicaid beneficiary from 4:00 PM to 9:30 PM, resulting in an overlap of four hours and thirty minutes (4:00 PM to 8:30 PM). For these claims, ADV violated N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:77-4.12(d)(3), -(5), and N.J.A.C. 10:77-5.12(d)(3), -(5) by improperly billing for overlapping services.

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:77-4.12(d)(3), -(5) and N.J.A.C. 10:77-5.12(d)(3), -(5), providers shall maintain documentary support of all behavioral assistance services and intensive in-community mental-health rehabilitation services claims including “the exact date(s), location(s) and time(s) of service.” In addition, this provision states that providers must maintain documentary support for “the length of face-to-face contact [time], excluding travel time to or from the location of the beneficiary contact.”

 

D. ADV Improperly Billed for Travel Time

MFD reviewed records to determine whether ADV improperly included travel time within the length of face-to-face time that the servicing provider interacted with the beneficiary. MFD found that for 8 of the 523 claims, totaling $152.00, ADV included travel time to and/or from the location of the beneficiary as part of its billing for face-to-face services. For example, one SDED form documented that an ADV servicing provider provided services to a beneficiary on May 21, 2015, from 6:25 PM to 8:25 PM. A second SDED form for that same date documented that the same ADV servicing provider provided services to a different beneficiary from 8:50 PM to 10:50 PM. According to Google Maps, the locations of the two beneficiaries were 31.2 miles apart, requiring approximately 37 minutes of travel time. In that instance, ADV improperly billed travel time as part of its face-to-face services as it did not account for an additional 12 minutes needed for travel. For these claims, ADV violated N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:77-4.12(d)(3), -(5), and N.J.A.C. 10:77-5.12(d)(3), -(5) by improperly billing for travel time for the services provided.

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:77-4.12(d)(3), -(5) and N.J.A.C. 10:77-5.12(d)(3), -(5), providers shall maintain support of all behavioral assistance services and intensive in-community mental health rehabilitation services claims including “the exact date(s), location(s) and time(s) of service.” In addition, this provision states that providers must maintain support for “the length of face-to-face contact, excluding travel time to or from the location of the beneficiary contact.”

 

E. ADV Failed to Document Services with Progress Notes

For both intensive in-community mental health rehabilitation and behavioral assistance services, the servicing provider is required to document the services provided through progress notes. These notes provide necessary information regarding the treatment provided, the beneficiary’s response to the treatment, significant events that may affect the beneficiary’s condition or treatment, and other information pertinent to the beneficiary’s plan of care. The progress note differs from the SDED form in that the servicing provider completes the progress note, whereas the parent/guardian completes the SDED as an attestation as to the session’s date, duration, and location.

MFD reviewed ADV’s records to determine whether it maintained progress notes that supported its billed services. MFD found that for 4 of the 523 claims, totaling $499.00, ADV failed to document services with a progress note. In addition, MFD found that for 3 claims, totaling $446.50, ADV provided 1 progress note that was an exact duplicate of progress note entered for another claim, 1 progress note that was similar, meaning that it closely resembled another progress note, and 1 progress note that referenced an incorrect beneficiary. For example, one progress note from June 6, 2014 mirrored a progress note for the same beneficiary from May 30, 2014. For these progress notes, the only information that differed were minor grammar modifications. The latter of the two notes did not contain any unique information regarding the services provided during the session, advancement toward goals outlined in the plan of care or other relevant information. When progress notes lack critical information and/or mirror one another, it raises questions as to whether the services were provided and, if so, what transpired during those sessions. For these claims, ADV violated N.J.A.C. 10:49-9.8(b)(1), N.J.A.C. 10:77-4.12(e)(6), and N.J.A.C. 10:77-5.12(e)(6) by failing to maintain appropriate records.

Pursuant to N.J.A.C. 10:49-9.8(b)(1), providers are required “to keep such records as are necessary to disclose fully the extent of services provided.”

Pursuant to N.J.A.C. 10:77-4.12(e)(6), the provider shall maintain “weekly quantifiable progress notes toward defined goals as stipulated in the child/youth adult’s BASP.”

Pursuant to N.J.A.C. 10:77-5.12(e)(6), the provider shall maintain “for each discrete contact with the child/family, progress notes which address the defined goals stipulated in the child/youth or young adult's plan of care must be completed.”

 

F. ADV Billed Unsubstantiated Services

MFD reviewed records to determine whether ADV maintained proper documentation for the services billed to Medicaid. MFD found that for 19 of the 523 sample claims, totaling $755.84, ADV billed for services that were not sufficiently supported by documentation. Specifically, for some of these claims, ADV did not provide an SDED form that would support the claims, and for the remaining claims, the hours of service in the SDED conflicted with the hours billed and paid. For these claims, ADV violated N.J.A.C. 10:49-9.8(a) by failing to maintain appropriate records.

Pursuant to N.J.A.C. 10:49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

 

G. ADV Failed to Ensure the Minimum Age Requirement for Behavioral Assistants

For the claims in its sample, MFD reviewed each BAs driver’s license to determine whether the BA was at least 21 years of age prior to providing services for which ADV billed the Medicaid program. MFD found that for 2 of the 523 claims, totaling $117.00, one BA did not meet the minimum age requirement for performing services. For these claims, ADV violated N.J.A.C. 10:77-4.9(e) by allowing services to be provided by a BA under the age of 21 and by failing to maintain documentation to verify the BA’s age.

Pursuant to N.J.A.C. 10:77-4.9(e), “All direct care staff shall, at a minimum, have a high school diploma or equivalent, be 21 years old and have a minimum of one year relevant experience in a comparable environment and shall be supervised by appropriate clinical staff in accordance with this subchapter.”

Further, prior to the completion of the audit, MFD noted that ADV started the process of reimbursing the Medicaid program for these two claims by submitting a refund request to the state’s fiscal agent. MFD will still consider these claims as failed and will remain as part of the extrapolation for a final overpayment amount. MFD will then reduce the extrapolated amount by $117.00.

Summary of Overpayments

MFD determined that for the period from March 1, 2014 through February 15, 2019, ADV improperly billed and received payment for 47 of the 523 sample claims, totaling $3,042.59 (See Appendix A for Summary). These 47 failed claims contained a total of 52 exceptions, as some claims failed for multiple reasons. For purposes of ascertaining a recovery amount, MFD extrapolated the dollar error rate for 47 unique claims that failed to comply with applicable regulations to the total population of claims from which the sample claims were drawn, which in this case was 12,556 claims with a total amount of payment of $2,326,583.07. By extrapolating the sample of deficient claims to this universe of claims/reimbursement amount, MFD calculated that ADV received an overpayment of $76,663.68 that it must repay to the Medicaid program.[2] Since ADV repaid the Medicaid program $117.00 for 2 of the sampled claims, the overpayment amount is decreased to $76,546.68 ($76,663.68 - $117.00 = $76,546.68).

Recommendations

ADV must:

  1. Reimburse Medicaid the overpayment amount of $76,546.68.
  2. Adhere to state and federal regulations for Medicaid services provided by ADV and its contracted health care professionals.
  3. Before behavioral assistants are assigned case referrals, maintain documentation (i.e., successfully completed criminal background checks, valid driver’s licenses, proof of education and proof of age) to ensure compliance with state regulations.
  4. Ensure that ADV and its contracted health care professionals receive training to foster compliance with applicable state and federal regulations.
  5. Provide MFD with a Corrective Action Plan (CAP) indicating the steps ADV will take to implement procedures to correct the deficiencies identified in this Draft Audit Report.

ADV’s Response to the Draft Audit Report and MFD’s Comments

After being apprised of the findings above, ADV, through counsel, submitted comments and a CAP in response to MFD’s Draft Audit Report (See Appendix B). In this response, ADV offered several arguments against MFD’s findings and its  sampling and extrapolation methodology. MFD’s responses to ADV’s arguments are attached as Appendix C, entitled “ADV’s Comments and MFD’s Response.” As more fully explained in that document, MFD disagrees with most of the ADV’s arguments, but MFD gave credit in those circumstances when ADV provided sufficient and reliable documentation. For the majority of the claims at issue, however, MFD did not modify its findings. 

Further, ADV provided a CAP to address all of MFD’s recommendations above and thereby correct the deficiencies cited in this report. Thus, the only issue that ADV must address is the overpayment. MFD calculated that ADV received an overpayment of $76,546.68 that it must repay to the Medicaid program.

Sincerely,

KEVIN D. WALSH
ACTING STATE COMPTROLLER

DATE: 02/1/2021                               

By:  /s/Josh Lichtblau
Josh Lichtblau
Director, Medicaid Fraud Division

 

Cc: Kay Ehrenkrantz, Deputy Director, MFD
Don Catinello, Supervising Regulatory Officer, MFD
Glenn Geib, Recovery Supervisor, MFD
Thomas R. Calcagni; Attorney, Calcagni & Kanefsky LLP
Walter R. Krzastek; Attorney, Calcagni & Kanefsky LLP

 

Full Appendices can be found in the Full Audit Report PDF at the top of this page.

[1] As more fully explained below, MFD will reduce this overpayment amount by $117 to account for two claims for which ADV repaid the Medicaid program as a result of one of the audit findings.

[2] MFD can reasonably assert, with 90% confidence, that the true overpayment falls between $47,764 and $105,563 with the most likely overpayment (i.e., error point estimate) being $76,663.68.

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