OMIG 2013 Annual Report
The Office of the Medicaid Inspector General (OMIG) has published their 2013 Annual Report on its audit and recovery findings which include a record recovery of $879 million. According to report, "OMIG has now recovered more than $1.73 billion in improperly expended Medicaid funds over the past three years."
Social Adult Day Centers (SADC)
The report covers 50 investigations of social adult day programs to ensure compliance with Title 9 of NYCRR, NYC Building Department regulations and NYS Medicaid program regulations governing managed care and social adult day programs. The report makes specific reference to the investigation into two social day programs in the Bronx in April 2013. It also states OMIG along with the Medicaid Fraud Control Unit (MFCU) will continue their collaboration to ensure regulatory compliance.
Certified Home Health Agencies (CHHAs)
In 2013, OMIG posted the audit protocols for CHHAs. In conducting their audits, OMIG auditors verified that the required documentation was present to validate the delivery of services and that it was consistent with the plan of care. They also reviewed documentation to ensure there were no overlapping payments for dually eligible Medicare and Medicaid patients and that Medicaid spend-downs were met. In 2013, OMIG finalized three audits and found $66.2 million in overpayments. The tables included in the report break out the finding by project type and region.
OMIG also conducted audits on the Long Term Home Health Care Program (LTHHCP) and CHHA cost reports to verify per-visit and hourly rates calculated for various services. This also includes audits on the rate add-ons dedicated to worker recruitment, training, and retention. In 2013, two LTHHCPs audits were completed identifying overpayments of $1.1 million and one CHHA audit identifying overpayment of $1.7 million.
Home Health Care Demonstration Project
Under the Home Health Care Demonstration project’s initial phases, which began in 2000, the traditional approach for audits had been to examine each questionable dual-eligible claim on a claim-by-claim basis. This approach was problematic.
CMS then agreed to allow OMIG and the University of Massachusetts Medical School (UMass) to intiate a case sampling approach to determine the Medicare share of the cost of home health services claims for dual-eligible beneficiaries that were inadvertently submitted to and paid by Medicaid. In this case sampling methodology, OMIG and UMass applied an extrapolation technique to calculate payments that Medicaid had made that should have been paid by Medicare.
In October 2013 under this project, $211 million was recovered from the federal government for errors relating to dual eligible home care patients during 2007 through 2010.
CMS did not approve the continuation of the demonstration project for review periods beyond 2011. Therefore, OMIG reverted back to the traditional methodolgy of reviewing each individual claim for home care agencies on a case-by-case basis for every dual-eligible Medicaid claim. This approach has been overwhelming to our members who have had to submit an extraordinary amount of demand bills to Medicare and then have them undergo the appeals process. Utilizing this burdensome approach, OMIG has only recovered an additional $5.7 million in 2013, a significantly lower amount than that recovered in previous periods utilizing the case sampling methodolgy.
Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871