New Jersey Pushed to Return $32 Million in Home Health Payments

The New Jersey Department of Human Services improperly claimed more than $32 million in Medicaid payments for home health services that didn’t meet federal or state requirements, according to a recently released report from the U.S. Office of Inspector General.

Of 100 randomly reviewed claims for the state’s personal care services program submitted from August 2008 to December 2011, 17 lacked sufficient documentation and therefore didn’t qualify for Medicaid reimbursements, according to the report. It notes several errors made by the state, such as not providing physician’s certifications or nursing assessments and not meeting nursing supervision requirements.

Federal law requires Medicaid personal care services to be authorized by a physician and provided by a qualified individual in accordance with a treatment plan.

Based on the audit, investigators estimate that the New Jersey agency overbilled Medicaid for $32.2 million. This represents about 8% of the $393.4 million paid to New Jersey by the U.S. Department of Health and Human Services for the provision of home care to elderly and disabled residents during the audit’s timeframe, according to the report.

Investigators recommend that the agency refund the $32.2 million and issue guidance to providers regarding the requirements for claiming Medicaid reimbursement for home health services, according to the report.

The agency partially agreed with these recommendations, according to the report, but the state has argued that five claims should be removed from the audit sample due to “extraordinary circumstances” like providers no longer being in business or more than five years passing since the service date.

“The state concurs with some but not all of the findings concerning claims for personal care services,” Valerie Harr, director of the agency’s Division of Medical Assistance and Health Services, wrote in a letter in response to the audit. “The state respectively requests that the amount of the refund be recalculated.”

However, the report contends that state regulations require all Medicaid-enrolled providers to retain their records for five years, and that the random sample of claims were within this five-year period.

“We revised our findings to allow one claim for which the associated records were reportedly damaged by a flood,” the report states. “We maintain that our remaining findings and recommendations are valid. We find no reason to exclude any claims from our sample.”

Written by Kourtney Liepelt