New York's Claims for Medicaid Services Provided Under Its Traumatic Brain Injury Waiver Program Did Not Comply With Certain Federal and State Requirements

The New York State Department of Health (Health Department) claimed Federal Medicaid reimbursement for some traumatic brain injury (TBI) waiver program services that did not comply with certain Federal and State requirements. We estimated that the Health Department improperly claimed $54.3 million in Federal Medicaid reimbursement for unallowable TBI waiver program services and $663,000 for potentially unallowable TBI waiver program services.

The Health Department properly claimed Medicaid reimbursement for all TBI waiver program services during 11 of the 138 beneficiary-months in our random sample. However, the Health Department claimed Medicaid reimbursement for TBI waiver program services that were not allowable or were potentially unallowable for the 127 remaining beneficiary-months.

The claims for unallowable and potentially unallowable TBI waiver program services were made because (1) the centers did not ensure and document that all beneficiaries approved for TBI waiver program services were assessed by certified individuals and determined eligible for those services, (2) the Health Department did not ensure that the assessors and screeners properly evaluated beneficiaries for placement in the TBI waiver program, and (3) providers did not ensure that they documented TBI waiver program services billed and claimed reimbursement only for allowable ones.

We recommended that the Health Department (1) refund $54.3 million to the Federal Government; (2) work with CMS to resolve the claims, totaling $663,000, for which Medicaid reimbursement may have been unallowable; and (3) take steps to ensure that it complies with certain Federal and State requirements. The Health Department generally disagreed with our recommendations.