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Audit (A-07-10-03152)

07-05-2011
Nebraska Medicaid Payments for Personal Care Services

Executive Summary

Based on our random sample and the results of our computer data match, we estimated that Nebraska improperly claimed a total of $275,000 ($169,000 Federal share) in Medicaid reimbursement for personal care services (PCS) from January 1, 2007, through June 30, 2009. In addition, based on the potentially unallowable portion of the claims that we identified in our random sample, we estimated that the State agency claimed $7.4 million ($4.5 million Federal share) for PCS that may not have been allowable in accordance with Federal and State requirements.

Of the 100 paid claims in our random sample, portions of 11 claims were not allowable because of inaccurate or missing documentation, and portions of 87 claims may have been unallowable because providers' billing documentation differed significantly from the beneficiaries' Service Needs Assessment/Plans. In addition, our computer data match identified 464 instances in which providers billed for PCS during the beneficiaries' inpatient hospital stays, contrary to Federal and State requirements.

We recommended that Nebraska (1) refund $169,000 to the Federal Government; (2) work with the Centers for Medicare & Medicaid Services to determine whether payment and service documentation fully complied with Federal and State requirements and, if not, determine what portion of the $4.5 million (Federal share) in set-aside costs should be refunded to the Federal Government; and (3) strengthen controls by developing policies and procedures for more substantive documentation and prepayment and postpayment claim review to ensure that PCS claims are reviewed and paid in accordance with Federal and State requirements. In written comments on our draft report, Nebraska described corrective action that it had taken or planned to take.

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