The New York State Department of Health (DOH) made $16.6 million in Medicaid home health overpayments to home health providers over the course of 3-and-a-half years—and now few of those providers might be on the hook to pay back the agency.
“Home health care providers fill a great requirement by permitting sufferers to stay in their homes and ignore expensive placement in hospitals or rehabilitation centers,” New York State Comptroller Thomas P. DiNapoli stated in a press release issued Dec. 8. “Although, my auditors discovered several instances where the state Department of Health’s eMedNY billing system paid providers for weeks of service, when merely days of care had been given.”
That eMedNY system lacks important system controls to stop the inadequate payments identified in the audit, in accordance to a report from DiNapoli’s office.
The audit glanced at the time period between May 1, 2012, and Dec. 31, 2015. In 2012, the state executed an episodic payment system for Medicaid home health services, like long-term nursing, home health aide services, physical therapy, and social work/nutrition services. Under this system, certified home health agencies are paid for sixty-day episodes of care. If they give care for fewer than sixty days, they are supposed to get a pro-rated payment amount.
Although, 95 home health providers got Medicaid home health overpayments during the time period audited, in accordance to DiNapoli’s office. And 93 percent of the overpayments went to only twenty providers.
About $8.2 million in Medicaid home health overpayments were related to beneficiaries who transferred to a Medicaid managed long-term care plan during a sixty-day episode of care. The agencies that started treating them got full sixty-day payments instead of pro-rated amounts.
Around $7.1 million in Medicaid home health overpayments went to agencies that inaccurately billed multiple episodes during the sixty-day period from the start of care. The remainder of overpayments, about $1.3 million, were related to beneficiaries who began receiving care through one agency but then transferred to a different agency. In one case, an agency got $10,979 for a full sixty-day episode, even though it just served the beneficiary for ten days before the people switched to a different provider, in accordance to the press release.
DOH workers flagged potential issues with the eMedNY system controls while the episodic payment structure was being considered, in accordance to the Office of the Comptroller. Although, “insufficient resources” and the billing configuration under EPS meant that no moderate system controls were put in place.
The audit report consisted of 2 suggestions: the DOH should review the overpayments and try to recover them, “as appropriate”; and DOH should take measures to develop mechanisms to recognize and recover overpayments when billing doesn’t fit guidelines.
The Department of Health concurred with the suggestions and claimed that it is taking measures to deal the problem, involving by working with a new vendor—Xerox—to replace the present Medicaid billing system.
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