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Review of Medicaid Personal Care Services Claims Submitted by Providers in North Carolina

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Spotlight:Medicaid Personal Care Services

Are taxpayers footing the bill for improper Medicaid claims for personal care services? The answer is yes, according to the Office of Inspector General (OIG) of the Department of Health and Human Services.

Based on our sample results, we estimated that North Carolina improperly claimed $41.7 million (Federal share) for unallowable Medicaid personal care services during the period July 1, 2005, through June 30, 2007. Personal care services are generally furnished to individuals residing in their homes and not residing in institutional care settings, such as hospitals or nursing facilities. Medicaid beneficiaries are authorized for personal care services by a physician in accordance with a plan of treatment or with a service plan approved by the individual State.

Of the 100 sampled claim line items (items) in our random sample, 65 complied with Federal and State requirements, but 35 did not. Of the 35 items that were not compliant, 8 contained more than 1 deficiency. These deficiencies occurred because North Carolina did not have sufficient resources to adequately monitor the personal care services program for compliance with certain Federal and State requirements.

We recommended that North Carolina (1) refund $41.7 million to the Federal Government and (2) continue its efforts to implement additional procedures and controls for monitoring the providers of personal care services for compliance with Federal and State requirements. North Carolina concurred with our recommendations.

Filed under: Center for Medicare and Medicaid Services