OIG Audit Finds DOH Improperly Claimed $54 Million

The Office of the Inspector General (OIG) report reviewed claims for TBI waiver services from Jan. 1, 2007 through Dec. 31, 2009. DOH claimed approximately $196.5 million ($98 million Federal share) for TBI program services during this time - of that amount the OIG is asking DOH to repay $54.3 million. This number is based upon the following findings:

Regional Resource Development Centers (RRDCs) did not ensure and document all beneficiaries approved for TBI waiver program services were assessed by certified individuals and determined eligible for those services;
DOH did not ensure that the assessors and screeners properly evaluated beneficiaries for placement in the TBI waiver program; and
Service providers did not ensure that they documented TBI waiver program services billed and claimed reimbursement only for allowable ones.

Therefore, based upon their finding, OIG is asking for:

DOH to repay $54.3 million to the Federal Government;
Work with CMS to resolve the claims, totaling $663,000, for which Medicaid reimbursement may have been unallowable; and
Take steps to ensure that there is compliance with certain Federal and State requirements.

DOH does not agree with the OIG findings. DOH in response to the findings disputed OIG's interpretation of the Resource Utilization Group scores that are used to determine whether an individual is eligible for a nursing facility level of care - a standard that is required to receive TBI waiver services.

It is the position of DOH that not all of the alleged deficiencies identified within this audit warrant a full refund and a number of deficiencies are in dispute. The department said, "under state regulations, eligibility for the TBI waiver program is not based solely on the Hospital and Community Patient Review Instrument, but is supplemented by a number of other documents and reviews that serve to further support the requisite level of care determination."

LeadingAge NY will keep you posted on the resolution of the OIG report.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871