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Review of Medicaid Payments for Services Provided Under New York's Section 1915(c) Traumatic Brain Injury Waiver at Venture Forthe, Inc., From January 1, 2005, Through December 31, 2007

Based on our sample results, we estimated that the State improperly claimed approximately $3.2 million in Federal Medicaid reimbursement for traumatic brain injury (TBI) waiver program services provided by Venture Forthe, Inc. (Venture), that did not comply with Federal and State requirements during calendar years 2005 through 2007. In addition, we estimated that the State claimed $353,000 in Federal Medicaid reimbursement for services provided by Venture that may not have complied with Federal and State requirements. The State's TBI waiver program allows the State to claim Medicaid reimbursement for home and community-based services provided to individuals with TBIs who would otherwise require institutionalization in a nursing home.

We recommended that the State (1) refund $3.2 million to the Federal Government; (2) work with the Centers for Medicare & Medicaid Services to resolve the claims, totaling $353,000, for which Medicaid reimbursement may have been unallowable; (3) require the centers to ensure and document that all beneficiaries approved for services have been assessed by certified individuals and are eligible for TBI waiver program services; (4) provide adequate training to assessors on the Federal and State requirements for the TBI waiver program; and (5) require Venture to ensure that it documents services billed and claims reimbursement only for allowable TBI waiver program services. The State disagreed with our first recommendation and generally disagreed with our findings. We maintain that our findings and recommendations are valid.

Filed under: National Institutes of Health