Medicaid Program: Improper Medicaid Payments for Individuals Receiving Hospice Services Covered by Medicare
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The Office of the Inspector General notes that it is not expressing an opinion on the State Comptroller’s report or its results; however, the OSC encourages CMS to consider the report and its results and work with state partners to ensure the federal share of improper Medicaid payments identified is refunded to the Federal Government and to prevent such payments from occurring in the future.
Source Document
Audit Scope
The audit focused on New York State’s Medicaid program payments for dual-eligible individuals receiving Medicare-covered hospice services, examining both Fee-For-Service and Managed Care arrangements. It covered the period January 1, 2015 through July 31, 2019. The assessment included matching CMS Medicare hospice claims with New York Medicaid claims from the Transformed Medicaid Statistical Information System, analyzing the Department of Health’s eMedNY data, and reviewing a judgmental sample of 50 cases (35 with extensive Medicaid personal care services and 15 with large DME/supply usage) plus an additional 7 cases involving overlapping hospice and Medicaid aide services. It involved hospice providers, Medicaid MLTC plans, Local Departments of Social Services, and Medicaid providers to evaluate care coordination, documentation, billing practices, and policy compliance. It also examined related services exemptions (ALP, PACE, CHHA, LTHHCP) and the adequacy of processes to identify dual-eligibles who elect Medicare hospice.
Key Findings Summary
$527,397 in DME payments and other items where the diagnosis did not relate to terminal illness.
Department has not established sufficient controls to ensure Medicaid payments (FFS and managed care) are appropriate for dual-eligibles receiving Medicare-covered hospice care.
Approximately $50 million in actual and potential Medicaid overpayments, cost-saving opportunities, and questionable payments identified for dual-eligibles in Medicare-covered hospice care, including: $5.5 million in overpayments for services not allowed in conjunction with hospice or overlapping with hospice-covered benefits; $370,506 in overpayments for pe…
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AI-Assisted
AI Scope Summary
Identify and quantify improper Medicaid payments associated with dual-eligible individuals receiving Medicare-covered hospice, and develop actionable controls to prevent recurrence and improve coordination among hospice providers, MLTC plans, LDSS, and Medicaid.
AI-Generated Insight
This audit reveals significant gaps in New York’s oversight of Medicaid payments for dual-eligible individuals receiving Medicare-covered hospice, identifying about $50 million in actual and potential overpayments and emphasizing coordination weaknesses among hospice providers, MLTC plans, and LDSS. It underscores the need for better data sharing, beneficiary tracking, and policy alignment to ensure Medicaid pays only for services unrelated to terminal illness when hospice is the primary Medicare benefit.