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New York State Improperly Claimed Medicaid Reimbursement for Some Home Health Services Claims Submitted by Certified Home Health Agencies

The New York State Department of Health (State agency) claimed Federal Medicaid reimbursement for some home health services claims submitted by Certified Home Health Agencies (CHHAs) in the State that were not in accordance with Federal and State requirements. On the basis of our sample results, we estimated that the State agency improperly claimed at least $31.5 million in Federal Medicaid reimbursement during our January 1, 2007, through December 31, 2009, audit period.

Of the 100 claims in our random sample, 85 claims complied with Federal and State requirements, but 15 claims did not. Specifically, for 10 claims, the physician did not review the plan of care; for 2 claims, there was no plan of care; for 1 claim, the CHHA could not provide documentation to support the service; for 1 claim, the CHHA did not provide the service in the beneficiary's place of residence; and for 1 claim, the home health aide did not complete a basic training program. These deficiencies occurred because some CHHAs in the State did not comply with Federal and State requirements.

We recommended that the State agency (1) refund $31.5 million to the Federal Government and (2) issue guidance to CHHAs in the State on Federal and State requirements for physicians' orders and plans of care. The State agency did not indicate either concurrence or nonconcurrence with our recommendations.

Filed under: Centers for Medicare and Medicaid Services