Review of Medicaid Claims for Assisted Living Program Beneficiaries Who Are Hospitalized

EXECUTIVE SUMMARY:

Our objective was to determine whether Assisted Living Programs (ALPs) within New York State were improperly claiming Medicaid reimbursement when their residents were in hospitals or nursing homes.  State regulations prohibit Medicaid claims for ALP residents who are hospitalized or in nursing homes.  Assisted Living Programs improperly claimed Medicaid reimbursement for their residents who were in hospitals, but not in nursing homes.  Our report recommended that the State:  (1) institute eMedNY edits and ensure that they are effective to prevent ALPs from claiming and receiving Medicaid reimbursement when their residents are hospitalized, (2) utilize our database of 2,615 potentially improper claims to determine the amount of improper Medicaid reimbursement claimed by the ALPs for their residents who were in hospitals and return the Federal share of these overpayments to the Federal Government, and (3) reinforce its guidance to ALP providers that State regulations prohibit claims for their residents who are hospitalized.  The State disagreed with our findings and two of our three recommendations.  We believe that our findings and recommendations are valid.