New York Claimed Some Unallowable Costs for Services by New York State Providers Under the State's Developmental Disabilities Waiver Program

The State agency claimed Federal Medicaid reimbursement for some Office for People With Developmental Disabilities (OPWDD) waiver program services provided by New York State providers that did not comply with certain Federal and State requirements. Of the 137 beneficiary-months in our random sample, the State agency properly claimed Medicaid reimbursement for OPWDD waiver program services during 100 beneficiary-months. However, the State agency claimed $79,000 in Medicaid reimbursement for services that did not comply with certain Federal and State requirements for the remaining 37 beneficiary-months.

The claims for unallowable services were made because the State agency's and OPWDD's policies and procedures for overseeing and administering the waiver program were not adequate to ensure that (1) providers maintained all the required documentation to support services billed and claimed reimbursement only for services actually provided and (2) OPWDD waiver program services were provided according to written plans of care.

On the basis of our sample results, we estimated that the State agency improperly claimed $76.8 million in Federal Medicaid reimbursement for OPWDD waiver program services during calendar years 2006 through 2008.

We recommended that the State agency (1) refund $79,000 to the Federal Government, (2) work with CMS to determine the additional amount of overpayments for claims in the sampling frame, and (3) work with OPWDD to strengthen the agencies' policies and procedures. The State agency generally agreed with our findings and recommendations.