NY Claimed $23M Unallowable Medicaid Reimbursement Funds
By - The New York State Department of Health improperly claimed at least $23 million in Federal Medicaid reimbursement for unallowable supported employment services, according to a recent Office of the Inspector General (OIG) audit.
After a previous review on supported employment services in another state, OIG found numerous services that were improperly submitted for Federal Medicaid reimbursement. From that, the federal agency explained in its report that a review of New York’s supported employment services was warranted.
“The Health Department accurately claimed Medicaid reimbursement for all supported employment services during 65 of the 100 beneficiary-months in our random sample,” the report stated. “However, the Health Department claimed Medicaid reimbursement for unallowable supported employment services during the remaining 35 beneficiary-months.”
The NY Health Department made unallowable claims because providers did not ensure that services claimed were properly billed as supported employment services. Additionally, providers failed to ensure that supported employment services were provided only to beneficiaries with completed and approved care and supported employment plans.
Supported employment services were also not adequately documented, while supported employment services were not claimed at the appropriate level-of-support billing rate. Lastly, providers did not ensure that beneficiaries’ assessments and level-of-care evaluations were documented, and that beneficiaries were not eligible for similar services through the Education Department.
OIG recommended that the state agency refund the $23 million and comply with certain state and federal requirements on claim reimbursement. This included ensuring that the claim reimbursements were only for documented supported employment services and were at the appropriate level of support billing rate. Moreover, it was recommended that the health department “provide supported employment services only to beneficiaries for whom there is a completed and approved care and supported employment plan.”
The state agency must also ensure that each beneficiary approved for supported employment services has been assessed and evaluated to need the required level of car. This process must also be documented.
Lastly, OIG recommended that the health department “ensure that all beneficiaries receiving similar services from the Education Department are not claimed under its waiver programs.”
According to the report, the health department partially agreed with OIG’s recommendations. One area that the state agency disagreed with was how OIG interpreted how to calculate the level-of-support billing rate methodology. Additionally, the state agency disagreed with the waiver’s requirement for beneficiaries to be competitively employed in the integrated community labor market.
The NY Health Department also explained that it disagreed with OIG’s prerequisite for a specific assessment form to evaluate the need for the required level of care.
“After reviewing the Health Department’s comments and additional documentation, we maintain that our findings and recommendations are valid for 10 of the 14 sampled items,” the report stated. “For the remaining four sampled items, we understand the Health Department’s position that supported employment services provided were in accordance with the description of the service in the State regulations and revised our report accordingly.”
