Review of Medicaid Personal Care Services Claims Made by Providers in New York State

Based on our sample results, we estimated that New York State improperly claimed $100.3 million in Federal Medicaid reimbursement for personal care services claims submitted by providers during calendar years 2004 through 2006. Of the 100 claims in our sample, 61 complied but 31 did not comply with Federal and State requirements pertaining to nursing assessments, physicians' orders, nursing supervision, inservice training of personal care aides, or documentation of the time spent providing services. In addition, for the eight remaining claims in our sample, we estimated that the State claimed $15.3 million for Consumer Directed Personal Assistance Program (CDPAP) claims that may not have complied with State requirements regarding physicians' orders and nursing assessments. Personal care services are generally furnished to individuals in their homes. Examples of personal care services include cleaning, shopping, grooming, and bathing.

We recommended that the State (1) refund $100.3 million to the Federal Government; (2) improve its monitoring of the personal care services program to ensure compliance with Federal and State requirements; (3) work with CMS to resolve the eight CDPAP claims and, if applicable, refund the estimated $15.3 million in unallowable payments; and (4) promulgate specific regulations related to claims submitted under the CDPAP. The State disagreed with our first recommendation and agreed with our remaining recommendations.