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New York Improperly Claimed Medicaid Reimbursement for Some Bridges to Health Waiver Program Services That Were Not in Accordance With an Approved Plan of Care and Did Not Meet Documentation Requirements

Why OIG Did This Audit

During prior reviews, we determined that New York claimed Medicaid reimbursement for home and community-based services (HCBS) under Medicaid waiver programs that did not comply with Federal requirements. New York's Bridges to Health (B2H) was an HCBS waiver program.

As of April 1, 2019, New York discontinued the B2H waiver program and transitioned these services into a comprehensive child-focused waiver known as The Children's Waiver.

Our objective was to determine whether New York claimed Medicaid reimbursement for B2H waiver program services in accordance with certain Federal and State requirements.

How OIG Did This Audit

Our review covered New York's claims for Medicaid reimbursement for HCBS provided under the B2H waiver program during calendar years 2015 through 2017 (audit period) for 105,703 beneficiary-months totaling $149 million (Federal share). We reviewed a random sample of 100 beneficiary-months.

What OIG Found

During 8 of 100 sampled beneficiary-months, New York claimed Medicaid reimbursement for some B2H waiver program services that did not comply with Federal and State requirements. Specifically, services were not provided in accordance with the beneficiary's plan of care (four beneficiary-months), provider documentation did not support services billed (three beneficiary-months), and services were not provided in accordance with an approved level-of-care assessment (one beneficiary-month). In addition, during 32 beneficiary-months, New York claimed Medicaid reimbursement for B2H waiver program services in excess of the monthly allotment of services authorized in the associated beneficiaries' plans of care.

On the basis of our sample results, we estimated that New York improperly claimed at least $614,530 in Federal Medicaid reimbursement for services that did not comply with certain Federal and State requirements. In addition, we estimated that New York claimed $3.3 million in Federal Medicaid reimbursement for services that exceeded the monthly allotment of services authorized in beneficiaries' plans of care.

What OIG Recommends and New York's Comments

We recommend that New York (1) refund $614,530 to the Federal Government; (2) work with CMS to develop guidance through The Children's Waiver on claiming Federal Medicaid reimbursement for HCBS according to the monthly allotment authorized in beneficiaries' plans of care, which could have reduced or eliminated an estimated $3.3 million in payments made during our audit period; and (3) ensure providers claim Federal Medicaid reimbursement only for services in accordance with beneficiaries' plans of care and maintain the required documentation to support claims for services provided and level-of-care assessment approvals, according to the provisions in The Children's Waiver.

In written comments on our draft report, New York did not indicate concurrence or nonconcurrence with our first and second recommendations, generally agreed with our third recommendation, and described actions that it had taken or planned to take to increase its oversight of HCBS provided under The Children's Waiver. After reviewing New York's comments and additional documentation provided under separate cover, we revised our findings and related recommendations. We maintain that our findings and recommendations, as revised, are valid.

Filed under: Centers for Medicare and Medicaid Services