Healthcare Revenue Cycle Management, ICD-10, Claims Reimbursement, Medicare, Medicaid

Policy & Regulation News

New York State Agency Made $79K in Inappropriate Medicaid Claims

By Stephanie Reardon

State agency claimed Medicaid reimbursement for some home and community-based services provided by New York City providers that did not comply with Federal and State requirements.

- The Department of Health and Human Service (HHS) Office of Inspector General (OIG) released the results of its audit on New York State’s Office for People with Developmental Disabilities (OPWDD) Medicaid waiver program. The audit was to determine if the State agency claimed Medicaid reimbursement for some home and community-based services (HCBS) provided by New York City providers that did not comply with Federal and State requirements.

The Centers for Medicare & Medicaid Services (CMS) funds the Medicaid program, which gives medical care to low-income and disabled beneficiaries. Each Medicaid program is monitored by individual States according to a CMS-approved State Plan which the State has outlined. In New York, the State agency implements the Medicaid program.

A state memorandum allows the OPWDD to offer the OPWDD4 waiver program. The OPWDD waiver program aims to help adults and children with developmental disabilities to live in the community rather than in an intermediate care facility. The State agency claims Medicaid reimbursement on a fee-for-service basis for OPWDD waiver program services provided to beneficiaries by OPWDD waiver program providers.
To be eligible for the OPWDD waiver program, a beneficiary must be a Medicaid recipient, be diagnosed with an intellectual or developmental disability, and be assessed to need a level of care equivalent to that provided in an intermediate care facility. Each beneficiary’s care plan is reviewed every six months.

Medicaid providers must document the extent of services provided to beneficiaries, and States may claim Medicaid reimbursement only for documented expenditures. Medicaid providers are required to create and update documentation to support Medicaid claims, including records necessary to disclose the nature and extent of services provided during care.

However, it was discovered that the State agency claimed Federal Medicaid reimbursement for some OPWDD waiver program services provided by New York State providers that did not comply with certain Federal and State requirements.

The audit determined that the State agency claimed $79,328 in Medicaid reimbursement for services that did not comply with certain Federal and State requirements for 37 out of 137 beneficiary months. Nine of these 37 months contained multiple problems.

The State agency claimed $72,263 for waiver services that were not appropriately documented for 20 beneficiary months, claimed $3,786 for services that were not rendered according to a beneficiary’s written plan of care for 18 beneficiary months, and claimed $302 for services that were not rendered at all for four months. In total, the audit estimates that the state agency claimed approximately $76,817,444 in improper Medicaid claims during calendar years 2006 through 2008.

“The claims for unallowable services were made because the State agency’s and OPWDD’s policies and procedures for overseeing and administering the waiver program were not adequate to ensure that (1) providers maintained all the required documentation to support services billed and claimed reimbursement only for services actually provided and (2) OPWDD waiver program services were provided according to written plans of care,” the report reads.

The OIG recommended that the State agency refund $79,328 to the Federal Government, work with CMS in determining the additional amount for inappropriate claims in the remaining 1,376,188 beneficiary-months that the State obtained Medicaid reimbursement (estimated at $76,738,116) during 2006 through 2008, and work with OPWDD to improve its policies on providing appropriate documentation for services and in following written plans of care.

The State agency agreed with the OIG’s findings for the first and third recommendation. However, the State agency did not agree with the OIG’s second recommendation in respect to the estimated amount overpaid. The State agency did agree that it would work with the CMS to establish the appropriate overpaid amount for the remaining beneficiary months.

In response, the OIG agreed with the State agency’s disapproval of the estimated recovery amount but will not include a different amount estimate.

 

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