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Review of New Mexico Medicaid Personal Care Services Provided by Coordinated Home Health

The State did not always ensure that Coordinated Home Health's (Coordinated) claims for Medicaid personal care services complied with certain Federal and State requirements. Based on our sample results, we estimated that Coordinated improperly claimed at least $11 million (Federal share) for personal care services during the period October 1, 2006, through

September 30, 2008. Personal care services may be provided to individuals who are not inpatients at a hospital or residents of a nursing facility, an intermediate care facility for individuals with intellectual disabilities, or an institution for mental disease. Examples of personal care services include, but are not limited to, cleaning, shopping, grooming, and bathing.

Of the 100 claims in our sample, 54 complied with requirements, but 46 did not. Three of the forty-six claims were partially allowable. The 46 claims contained a total of 60 deficiencies: 49 deficiencies on insufficient attendant qualifications and 11 deficiencies on other issues. As a result, Coordinated improperly claimed $8,000 for the 46 claims.

We recommended that the State (1) refund to the Federal Government the $11 million paid to Coordinated for unallowable personal care services and (2) ensure that personal care services providers maintain evidence that they comply with Federal and State requirements. Coordinated disagreed with almost all of our findings, and the State disagreed with our recommended refund amount. The State also said that some of the documentation requirements are not Federal requirements; they are State requirements, which do not require recovery of payments.

Filed under: Centers for Medicare and Medicaid Services