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Audit (A-02-10-01022)

11-29-2012
New York Improperly Claimed Medicaid Reimbursement for Some Home Health Services Claims Submitted by Certified Home Health Agencies in New York City

Executive Summary

The State claimed Federal Medicaid reimbursement for some home health services claims submitted by Certified Home Health Agencies (CHHA) in New York City that were not in accordance with Federal and State requirements. Based on our sample results, we estimated that the State improperly claimed $69.1 million in Federal Medicaid reimbursement during our January 1, 2007, through December 31, 2009, audit period.

CHHAs provide preventive, therapeutic, and/or rehabilitative services to Medicaid beneficiaries. Pursuant to Federal regulations, home health services are provided to a beneficiary at the beneficiary's place of residence and on his or her physician's orders as part of a written plan of care that the physician reviews every 60 days.

Of the 100 claims in our random sample, 83 claims complied with Federal and State requirements, but 17 claims did not. Of the 17 claims, 1 contained more than 1 deficiency. Specifically, for 17 claims, the plan of care was not reviewed every 60 days and, for 1 claim, the provider was unable to document that the service was provided. These deficiencies occurred because some CHHAs in New York City did not comply with Federal and State requirements.

We recommended that the State (1) refund $69.1 million to the Federal Government and (2) issue guidance to CHHAs in New York City on Federal and State requirements for physicians' orders and plans of care. The State did not indicate either concurrence or nonconcurrence with our recommendations.

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