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Transcript for audio podcast:
Traumatic Brain Injury Waiver Program

From the Office of Inspector General of Department of Health and Human Services

[James Edert] Hello, I'm James Edert, Regional Inspector General for Audit Services in New York. I'm here with Brenda Tierney, Audit Manager, from our Albany office. We're talking about the audit report issued to the New York State Department of Health about its claims for Medicaid services provided under the traumatic brain injury waiver program. Brenda, first explain a waiver program.

[Brenda Tierney] Sure. There are many types of Medicaid waiver programs. The traumatic brain injury waiver program allows States to seek Federal reimbursement for home and community-based services not usually covered by Medicaid.

[James Edert] What are home and community-based services and who is eligible to receive them?

[Brenda Tierney] Home and community-based services are generally provided to Medicaid patients in the community rather than in an institutional setting, such as a hospital or nursing facility. For the waiver program we reviewed, an individual must have a traumatic brain injury, or a TBI, and need a nursing home level of care.

[James Edert] How does the New York Department of Health determine the care a patient needs?

[Brenda Tierney] The Department uses two forms. The first is called the Hospital and Community Patient Review Instrument, or PRI form. It is used as a clinical tool to assess the patient's condition. The second form is called the SCREEN, and is a tool to assess the support available to patients in their homes and communities before referring them for care in that setting. Used together, the information on these forms helps assign something known as the "RUG score." The RUG score determines whether States can file claims with the Federal Government to receive payment for services provided to traumatic brain injury patients in their homes or communities.

[James Edert] What were the biggest areas of concern you noted in the report?

[Brenda Tierney] Well, for 92 of the 138 cases in our sample, patients received RUG scores that indicated they did not meet the Department's requirements for a nursing home level of care. The State, however, sought and received payment for these services. Other areas of concern included undocumented services and assessments, services not provided in accordance with an approved care plan, and assessments conducted by uncertified individuals.

We recommended that the Department of Health refund over $54 million dollars to the Federal Government and work with the Centers for Medicare & Medicaid Services to resolve an additional $662,000 dollars.

[James Edert] The Department of Health, in its comments, stated that you misinterpreted the RUG scores, that you did not consider all relevant information, and noted that eligibility is not solely based on a single form.

[Brenda Tierney] The Department of Health, on many occasions, indicated that the staff running the waiver program had personal knowledge of patients' medical conditions that we, as auditors, could not know based on just a single form.

We fully acknowledge that we do not have any medical background and would never make medical determinations. The assessment forms, the PRI and the SCREEN, are tools that look at the patient's clinical condition, including medical, behavioral, daily living, and specialized service assessments, as well as the patient's care and support in the community.

While a referral was made for community-based care, the RUG score for these sampled cases indicated that the patient did not qualify for the type of care required to participate in the program. That RUG score is determined using the responses recorded during the patient's assessment by appropriate medical personnel.

[James Edert] I understand that the Department of Health has recently re-categorized the RUG scores.

[Brenda Tierney] Yes, that's correct. During our audit period, patients could have received one of 16 possible RUG scores - but only 12 of them met the Department of Health's requirements for nursing home level of care. In our sample, patients who did not qualify for the waiver program received one of the four non-qualifying scores. The Department of Health has since added those four RUG scores to the list.

[James Edert] Thank you for sharing this information on New York State's traumatic brain injury waiver program.

[Brenda Tierney] Thank you.


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