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New York Improved Its Monitoring of Its Personal Care Services Program But Still Made Improper Medicaid Payments of More Than $54 Million

Why OIG Did This Audit

Prior OIG audits found that New York did not effectively monitor its Medicaid personal care services program and, as a result, made more than $375 million in Federal Medicaid payments for services that did not comply with Federal and State requirements. This audit was conducted to determine whether New York made improvements to its monitoring of the program and whether any of those improvements were effective.

Our objective was to determine whether New York claimed Medicaid reimbursement for personal care services that complied with Federal and State requirements.

How OIG Did This Audit

Our audit covered 5,675,965 claims with Federal Medicaid payments totaling $438 million for personal care services provided during calendar years 2015 through 2018 (audit period). We reviewed a stratified random sample of 140 claims and determined whether the services complied with Federal and State requirements.

What OIG Found

New York claimed Federal reimbursement for personal care services that did not comply with certain Federal and State requirements for 28 of the 100 sampled claims. Specifically, New York received reimbursement for personal care services for which there was (1) no valid nursing or social assessment, (2) no independent medical review, (3) no valid physician's order or the order was not timely, (4) no documentation of services provided, and (5) no plan of care. Additionally, for some claims, the personal care aide who provided the associated services had not undergone a timely criminal history check or did not meet training requirements.

The unallowable claims occurred because New York's monitoring of the personal care services program was not adequate to ensure that services complied with Federal and State requirements. However, we noted that in 2017, New York made some improvements to its monitoring of the program.

On the basis of our sample results, we estimated that New York improperly claimed at least $54.5 million in Federal Medicaid reimbursement for personal care services during our audit period. In addition, the health and safety of some Medicaid beneficiaries may have been put at risk because their personal care aides had not undergone a criminal history check prior to providing personal care services or did not meet training requirements.

What OIG Recommends and New York's Comments

We recommend that New York refund $54.5 million to the Federal Government, continue to improve its monitoring of local districts, and reinforce with local districts and personal care services providers Medicaid requirements related to personal care services.

In written comments on our draft report, New York did not specifically indicate concurrence or nonconcurrence with our recommendations; however, it described steps that it plans to take to address them, including pursuing recovery of any payments determined to be inappropriate, reviewing each local district at least once every 2 years, reinforcing and ensuring providers comply with criminal history check and training requirements and implementing an electronic visit verification system. We commend New York for its planned steps to improve its monitoring of the personal care services program and to ensure local districts and personal care services providers comply with Medicaid requirements related to personal care services. We are also available to discuss our methodology with New York should it be necessary.

Filed under: Centers for Medicare and Medicaid Services