YELLOW SHEET
Office of the State Auditor of Missouri
Claire McCaskill
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YELLOW SHEET Office of the State Auditor of Missouri |
Report No. 2006-69
November 2006
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Additional efforts are needed to identify and collect overpayments and opportunities exist to further standardize authorized services The state spent approximately $233 million during fiscal year 2005 for home and community-based personal care services provided to Medicaid eligible elderly and disabled individuals. We focused audit efforts on determining (1) whether improvements are needed in the Department of Heath and Senior Services' (DHSS) ability to detect and recoup improper program payments to providers, and (2) the status of recommendations addressed in our 2004 report titled "Medicaid Personal Care Services Program" (Report No. 2004-02). |
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Recoupment of overpayments limited
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During fiscal year 2005, Department of Social Services, Division of Medical Services (DMS) personnel initiated recoupment of approximately $503,000 in program funds, primarily as the result of quality assurance (QA) provider reviews. However, recoupment of Medicaid funds amounted to only .2 percent of $233 million in program expenditures for fiscal year 2005. In 2001, the U.S. Government Accountability Office reported Illinois, Texas, and Kansas identified improper payment error rates of 4.7 percent, 7.2 percent, and 24 percent, respectively. An assumed error rate of 1 percent would equal $2.3 million in improper program payments. (See pages 9 and 18) |
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Efforts to detect overbilling limited and not timely |
DHSS has relied on its QA process and hotline complaints to detect provider overbilling. However, QA's review process provided less assurance overbilling would be detected because QA's responsibilities to detect overbilling had not been clearly defined, and reviews of provider client files and aides had been limited. In addition, QA's goal of reviewing each of the 380 providers every 2 years had not been met. (See page 10) |
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RCF billings not reviewed on regular basis
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Residential care facilities (RCF) also provided |
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No review of Mental Health's employee disqualification registry |
Review of DHSS's efforts to detect disqualified provider employees disclosed 16 disqualified individuals on Mental Health's employee disqualification registry that may have worked with clients from July 2000 through May 2006. Thirteen of these employees worked in the home and community-based services program, while three additional individuals worked as aides in the consumer directed care program. (See page 14) |
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Excluded providers not reviewed |
DHSS personnel did not review RCFs to determine whether those providers had been included on the U.S. Department of Health and Human Services' OIG exclusion listing. According to state law, the department is required to investigate whether or not principals in the operation are excluded from Medicaid, because it cannot issue a license to an RCF if any principals involved in the operation are excluded from participation in Medicaid. (See page 16) |
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Adequate oversight of providers lacking |
DHSS lacked oversight of provider billings and other deficiencies because it did not establish an adequate management reporting system capable of providing useful information on providers. QA is transitioning to an automated reporting system, but it will be approximately a year before it is fully implemented. (See page 17) |
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DMS efforts limited |
DMS initiated recoupment of approximately $503,000 in program funds during fiscal year 2005. However, potential recoupments have been minimal because DMS audits of home and community-based providers have been limited. DMS did not dedicate adequate staff resources to review program providers for possible overbilling and/or fraud. Recoupments have also been minimal because of limited referrals from QA to DMS personnel. (See page 18) |
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Opportunities may exist to further standardize authorized services |
In 2004, we reported DHSS had not established criteria to determine and control the number of personal care service hours Medicaid clients could be authorized on a statewide basis. DHSS implemented one of two recommendations related to that situation. Follow-up efforts disclosed DHSS has made some progress in achieving more uniform allocation of personal care services. However, the St. Louis region continued to exceed other regions in terms of authorized services and, although officials had conducted some analyses of why it occurred, these analyses were not adequate to determine why the differences existed. Officials implemented our recommendation to improve the timeliness of violation notifications to providers. (See pages 6 and 25) |
