Rate Setting and Audit Section

The Medicaid Rate Setting and Audit Section manages annual reimbursements made under various long-term care reimbursement methodologies, including methodologies for specialized services, for Medicaid recipients receiving long-term care services in nursing facilities and adult day health care facilities. The annual expenditures of such expansive sums under a capped amount of federal fund participation with open-ended recipient rights to services necessitates constant interim monitoring projections, analyses and meetings with federal, state and contracted auditors. Technical, comprehensive and detailed analyses are prepared and constantly updated to ensure maximum program effectiveness and accountability. Louisiana Medicaid Rate Setting and Audit Section contracts with CPA consultant firms for the development of rate methodologies and for the audit of Medicaid providers participating in the long-term care programs. This section monitors these contracts, reviews, and approves the consultants’ audits, desk reviews, and audit programs and then authorizes payments.

To speak to someone from this office, call Medicaid Rate Setting and Audit Section at (225) 342-6116. 

Long-Term Care Cost Audit Reports

The Louisiana Department of Health (LDH) has a contract with a professional CPA firm to perform on-site audits of Medicaid cost reports submitted by nursing facilities, intermediate care facilities for Individuals with Intellectual Disabilities (ICF/IID), and adult day health care (ADHC) facilities. In addition to the audit function,  the contractor performs desk reviews of Medicaid cost reports for private nursing facilities, ICF/IID, and adult day health care facilities. The contractor calculates rates for the private ICF/IID, adult day health care facilities, and nursing facility specialized services [Skilled Nursing – Infectious Disease (SN/ID), Skilled Nursing – Technology Dependent Care (SN/TDC) and Neurological Rehabilitation Treatment Programs (NRTP)].  These functions are performed to determine that providers are reimbursed within the Department’s regulations and according to the Medicare Provider Reimbursement Manual (HIM-15) principles. The LDH Rate and Audit Review Section maintains all of the audit information compiled by the contractor.  This section follows up on audit issues, as necessary.

Nursing Home Case Mix Reimbursement Methodology

 This reimbursement methodology is based on using the Medicare Minimum Data Set to determine the level of needs of Medicaid recipients in nursing facilities and to ensure that nursing facilities receive a level of reimbursement commensurate with the level of services needed for each resident.  It requires that nursing facilities expend a set amount of funding received for the provision of direct care services.  If expenditures for direct care are not at an acceptable level, the nursing facility must reimburse the department for a portion of the funding received. This methodology assures reasonable access to care for persons needing high levels of nursing facility care.

Minimum Data Set (MDS) Medical Records Review Overview

A periodic case mix medical records review is completed for all Louisiana licensed nursing home facilities as appropriate under state rule. The case mix medical record review is conducted for the following assessment selection:

• A minimum of 20% of the occupied census or 10 medical records, whichever is greater, and
• A random sample of those residents in each of the Resource Utilization Groups (RUG-III) where possible