New York State Improperly Claimed Medicaid Reimbursement for Continuous 24-Hour Personal Care Claims

Most of the New York Department of Health's (State agency) claims for Federal Medicaid reimbursement for high-dollar continuous 24-hour personal care services claims did not comply with Federal and State requirements. On the basis of our sample results, we estimated that the State agency improperly claimed at least $12 million in Federal Medicaid reimbursement for high-dollar continuous 24-hour personal care services that did not meet Federal and State requirements. High-dollar claims included services for beneficiaries with total Medicaid paid amounts greater than $10,000.

Of the 100 claims in our random sample, 20 complied with Federal and State requirements, but 80 did not. Our audit covered Medicaid beneficiaries residing outside New York City and Ulster County.

These deficiencies occurred because (1) certain local districts did not comply with, and stated that they were unaware of, requirements related to continuous 24-hour personal care services and (2) the State agency did not adequately monitor the local districts and personal care providers for compliance with these requirements.

We recommended that the State agency (1) refund $12 million to the Federal Government, (2) issue guidance to the local districts related to the requirements for continuous 24-hour personal care services, and (3) improve its monitoring of local districts and personal care providers to ensure their compliance with Federal and State requirements related to continuous 24-hour personal care services. The State agency did not indicate concurrence or nonconcurrence with our first recommendation (financial disallowance) and generally agreed with our remaining recommendations.