New York Overbilled Medicaid Home Care Program by $75 Million

New York’s Medicaid agency claimed reimbursement for some in-home care services that were not in accordance with Medicaid requirements, to the tune of $74.8 million, according to the Office of Inspector General.

The state did not provide documentation of services claimed, claimed reimbursement for services that were not authorized or supported, and for claims which documentation was not completed in a timely manner. The state did not effectively monitor its consumer-directed personal assistance program (CDPAP) to comply with requirements, OIG stated.

New York’s CDPAP, operated by the state’s Medicaid agency, allows Medicaid beneficiaries flexibility in choosing their personal care, home health or nursing services provider. CDPAP also encompasses home health care services and nursing services, and care orders must be based on a physician’s order.

OIG looked at a sample of 120 claims from the audit period of January 2012 through June 2016, during which time New York claimed Federal Medicaid reimbursement totaling $1,156,790,090. Of the sampled claims, the state agency improperly claimed reimbursement for 27 claims, including:

  • 14 unallowable claims for documentation not provided
  • 7 claims for services not authorized or supported
  • 4 claims for documentation not completed in a timely manner
  • 3 claims for services outside of authorization period

Based on the sample, OIG estimated the state improperly claimed nearly $75 million. Some of the improper claims were chalked up to documentation mishaps, such as billing for the incorrect number of units, not providing enough supporting documentation and submitting claims too late.

OIG recommends that the state agency refund the $74.8 million amount to the federal government and reinforce guidelines to the social services districts and providers related to the program’s documentation and billing requirements.

The audit period took place during a time of “high levels of change across New York’s Medicaid program and encompassed the transitioning of Medicaid beneficiaries from fee-for-service to managed long-term care plans,” the state agency indicated.

Written by Amy Baxter

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Amy Baxter
Assistant Editor at Home Health Care News
When not writing about all things home health, Amy fulfills her lifelong dream of becoming a pirate by sailing in regattas and enjoying rum. Fun fact: she sailed 333 miles across Lake Michigan in the Chicago Yacht Club "Race to Mackinac."



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