Review of Medicaid Claims for Adult Mental Health Rehabilitation Services Made by Community Residence Providers in New Jersey

New Jersey (the State) did not claim Federal Medicaid reimbursement for adult mental health rehabilitation (AMHR) services provided by community residence rehabilitation (CRR) providers in accordance with Federal and State requirements. Based on our sample results, we estimated that the State improperly claimed $30.6 million in Federal Medicaid reimbursement during our June 12, 2005, through December 26, 2007, audit period.

The State elected to include coverage of Medicaid AMHR services provided to mentally ill beneficiaries residing in community residences, such as group homes, supervised apartments, and family care homes. Examples of AMHR services include assistance with daily living skills, managing medication, individual services coordination, counseling, support services, and crisis intervention.

We found the following seven types of deficiencies: CRR provider staff did not meet education and training requirements; service plan requirements were not met; the providers' staffing levels were not consistent with the required level of care or the provider claimed a higher level of care than was recommended; weekly progress notes were not documented; a registered nurse did not conduct a face-to-face visit within the required time period; services were not documented, supported, or allowable; or nursing assessment requirements were not met.

The deficiencies occurred because (1) State regulations were not consistent with Medicaid State plan requirements, (2) certain CRR providers did not comply with Federal and State requirements, and (3) the State did not adequately monitor CRR providers for compliance with certain Federal and State requirements.

We recommended that the State (1) refund $30.6 million to the Federal Government, (2) provide CRR providers with guidance to help ensure that they comply with Medicaid State plan requirements, and (3) improve its monitoring of providers' claims to ensure compliance with Federal and State requirements. The State generally agreed with our findings.