Kusserow’s Corner: OMIG Reports Identifying Half a Billion Dollars in Erroneous Home Health Payments

In my blog over the last couple of months, I have been reporting on numerous enforcement efforts in dealing with home health fraud and about around the country. The latest news on the subject comes from the New York Office of the Medicaid Inspector General (OMIG) that reported identifying more than $496 Million in home health erroneous payments$496 Million Identified in Home Health Medicaid Error Payments. They found errors relating to home care recipients who are dually-eligible for both Medicare and Medicaid funds. This resulted in NY receiving a $211 million payment, representing the state’s share of the funds, on October 1, 2013, representing the largest single monetary recovery in OMIG’s history. These recoveries are part of the Third-Party Liability Home Health Care Demonstration Project, a federal project looking at home health care involving dual-eligible recipients, conducted in conjunction with the University of Massachusetts Medical School.

In the case of dual-eligible recipients, home health care providers should first bill Medicare, and then bill Medicaid for whatever portion of the bill Medicare does not pay. Once that process is complete, the dual-eligible recipient’s bill is paid in full. Having dual eligibility in both Medicare and Medicaid is not an unusual circumstance. In most cases, Medicaid is the payer of last resort for dual-eligible recipients. In the cases reflected in these overpayments, bills for these home health care patients were inadvertently sent to Medicaid before first sending them to Medicare and following the correct process. The overpayment by NY was determined by using sampling methodology by OMIG and University of Massachusetts Medical School staff. They applied an extrapolation technique to calculate payments that New York State Medicaid had made that should instead have been made by Medicare first.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

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Copyright © 2013 Strategic Management Services, LLC. Published with permission.