More on Claims Processing

OIG: Medicaid 'incorrectly' paid $724M for personal care services

In a new sample audit of Medicaid payments, the Office of the Inspector General found the government "inappropriately paid" 6.5 million claims for a total of $724 million. The claims were for personal care service provided by attendants who didn't have proof of federally required qualifications.

Eighteen percent of the claims that Medicaid reimbursed for personal care services between Sept. 1, 2006 and Aug. 31, 2007 should not have been paid because they lacked documentation of the personal care provider's criminal background checks, minimum age, health status, education or training requirements, the study found.

Respondents for 2 percent of the sample claims reported no record of ever providing services to the beneficiaries named in the claims data.

The OIG also discovered that personal care service is on the rise. Combined state and federal Medicaid expenditures for such services totaled $9.9 billion in 2006, up 20 percent from 2004.

For 43 percent of these inappropriate claims, OIG investigators said they received some documentation regarding the attendants, such as identification, but none to show that the attendants met any of the qualifications. For the remaining 57 percent of the improper claims, the OIG received documentation to support that attendants met some, but not all, of the qualifications. 

Respondents failed to provide documentation of attendant background checks for 5 percent, or 1.7 million claims. For 1.2 million claims, Medicaid did not have age documentation, and for another 451,480 claims there was no proof of education, the OIG said.

The OIG recommended that the Centers for Medicare & Medicaid Services work with states to ensure that Medicaid claims for personal care service provided by attendants with undocumented qualifications are not paid and to "take action" regarding the inappropriately paid claims identified in the new review. CMS officials agreed with both recommendations.