HHS OIG Finds Ulster County DSS 100% Non-Compliant, Demands Refund of $6.3 Million for Unallowable Continuous 24-Hour Personal Care Services

This month, the United States Department of Health and Human Services Office of the Inspector General (“HHS OIG) released its audit report for Ulster County’s 24-hour personal care services program.

After agreeing to settle its 2011 audit with New York City for $70 million, HHS OIG turned its focus to the rest of New York State to determine whether a systemic compliance problem existed concerning Federal Medicaid reimbursement of continuous 24-hour personal care claims.  In addition to the state-wide review, HHS OIG separately audited Ulster County due to a potentially high risk of billing errors because the county, according to officials in the county’s Department of Social Services, never conducted an independent medical review of continuous 24-hour personal care claims.

The March 2015 report found that Ulster County claimed $12.6 million in total Medicaid reimbursement, with $6.3 million requested from the Federal government.  Of the sample claims reviewed, HHS OIG found that Ulster County failed to meet Federal and State requirements of assessing and approving continuous 24-hour personal care services in each claim, resulting in 100% non-compliance.

HHS OIG’s report states that Ulster County made claims for unallowable services because providers did not ensure that the following regulatory requirements were met[1]:

No independent medical review

1. No nursing assessment
2. No physician’s order
3. Physician’s order not completed within 30 days of medical examination
4. No social assessment

While the New York State Department of Health (“NYSDOH) agrees that its personal care services programs need improvement to ensure compliance with Federal and State regulations, it did not expressly agree or disagree with the alleged overpayment amount.  In its response to HHS OIG, NYSDOH explained that the Office of the Medicaid Inspector General (“OMIG) is currently in the process of reviewing the audit’s findings, after which it will determine whether a refund is appropriate.  HHS OIG, however, is standing by its findings and recommendations in both reports and will continue to seek repayment.

The HHS OIG report for Ulster County report can be found here.

For more information, please contact the author, David R. Ross, who served as Acting New York State Medicaid Inspector General under governors Pataki and Spitzer, as well as General Counsel, Deputy Medicaid Inspector General, and Director of Audits and Investigations for the Office of the Medicaid Inspector General (OMIG). He can be reached at (518) 462-5601 or via e-mail at dross@oalaw.com.

[1] New York State requirements can be found in 18 N.Y.C.R.R. § 505.14.