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New Jersey Did Not Always Claim Federal Medicaid Reimbursement for Personal Care Services Made by Bayada Nurses, Inc., in Accordance With Federal and State Requirements

The New Jersey Department of Human Services (State agency) did not claim Federal Medicaid reimbursement, for some personal care services claims that Bayada Home Health Care (Bayada) submitted, in accordance with Federal and State requirements. Based on our sample results, we estimated that the State improperly claimed $774,000 in Federal Medicaid reimbursement during our January 1, 2008, through June 30, 2009, audit period. Personal care services are generally furnished to individuals residing in their homes and not residing in hospitals, nursing facilities, intermediate care facilities for persons with intellectual disabilities, or institutions for mental diseases. A physician authorizes personal care services for Medicaid beneficiaries within a plan of treatment or according to a service plan approved by the individual State. Examples of personal care services are cleaning, shopping, grooming, and bathing.

The American Recovery and Reinvestment Act of 2009, enacted February 17, 2009, provided, among other initiatives, fiscal relief to States to protect and maintain State Medicaid programs in a period of economic downturn. For the recession adjustment period (October 1, 2008, through December 31, 2010), the Recovery Act provided an estimated $87 billion in additional Medicaid funding.

Of the 100 claims in our random sample, 90 claims complied with Federal and State requirements, but 10 claims did not. Of the 10 noncompliant claims, 1 contained more than 1 deficiency. These deficiencies occurred because some of Bayada's office managers did not ensure that personal care services claims complied with certain Federal and State requirements.

We recommended that the State agency (1) refund $774,000 to the Federal Government and (2) direct Bayada to ensure that all of its offices comply with Federal and State requirements. Bayada disagreed with most of our findings and our recommended financial disallowance. The State agency disagreed with our first recommendation (financial disallowance) and did not indicate concurrence or nonconcurrence with our other recommendation.

Filed under: Centers for Medicare and Medicaid Services