Review of Personal Care Services Provided by Tri-State Home Health and Equipment Services, Inc., in the District of Columbia

We found that from July 1, 2006, through September 30, 2007, the District of Columbia (the District) paid Tri-State Home Health and Equipment Services, Inc. (Tri-State), $1.6 million ($1.1 million Federal share) for personal care services that did not comply with the Medicaid plan or waiver requirements for allowable hours of service or that were not provided. The District's Medicaid plan authorizes personal care services, which provide assistance with activities of daily living including bathing, grooming, and eating, for up to 8 hours per day and 1,040 hours during any 12-month period. The District also provides personal care services through a section 1915(c) waiver that allows up to 16 hours of services per day.

We set aside for CMS's adjudication $1.2 million ($808,000 Federal share) paid on behalf of 44 beneficiaries for whom Tri-State claimed hours of service under the waiver. Tri-State documented that it had submitted requests for waiver services for these beneficiaries but did not have evidence that it had received preauthorization for services under the waiver. We also determined that the District did not ensure that all of Tri-State's personal care aides met the District's qualification requirements.

We recommended that the District (1) refund $1.1 million for claims in excess of State plan limits paid without documentation of the required authorization, (2) refund $5,000 for claims paid for services that were not provided, (3) work with CMS to determine the allowability of $808,000 paid for waiver claims for which preauthorization of services was not adequately supported, (4) implement prepayment controls to monitor personal care service claims for compliance with Federal and District requirements, and (5) provide more effective monitoring of personal care aides' compliance with qualification requirements. The District concurred with our recommendations and described the actions that it had taken, or planned to take, to address them.