HHS OIG, Audit - Tennessee Home and Community-Based Mental Retardation Services for July 1, 2002, Through

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HHS OIG, Audit - Tennessee Home and Community-Based Mental Retardation Services for July 1, 2002, Through

Suwyig - Hhs Office Of Inspector General

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23 pages

Slovak

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,," ~DEPARTMENT OF HEAlLTH &. HUMAN SERVICES Office of Inspector General( t'(1-,¡". ..1I""JQ Washington, D.C. 20201 ~'~l"'YIC'S"'. SEP 1 3 200/ TO: Kerry Weems Acting Administrator Centers for Medicare & Medica' Services~~ FROM: oseph E. Vengr' Deputy Inspector General for Audit Services SUBJECT: Tennessee Home and Community-Based Mental Retardation Services for July i, 2002, Through June 30, 2003 (A-04-03-03026) Attached is an advance copy of our final report entitled "Tennessee Home and Community-Based Mental Retardation Services for July 1, 2002, Through June 30,2003." We wil issue this report to the State Medicaid agency within 5 business days. Tennessee's State Medicaid agency oversees section 1915(c) waivers to provide home and community-based services (HCBS) to Medicaid beneficiaries with mental retardation and developmental disabilities. Under a contract with the State Medicaid agency, the Division of Mental Retardation Services (DMRS) manages the HCBS waivers and contracts with local entities to provide HCBS to approximately 4,300 mentally retarded and developmentally disabled individuals in the community. From July 1, 2002, through June 30, 2003, the State Medicaid agency claimed Federal reimbursement of nearly $150.6 million in HCBS costs. Our objectives were to determine whether the State Medicaid agency claimed Federal reimbursement for HCBS that were adequately supported in the providers' records and provided in accordance ...

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Nombre de lectures	124
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Page 2 Kerry Weems

• One claim was for services that exceeded the allowed level of care specified in the beneficiary’s plan of care.

The Federal reimbursement for the unallowable claims occurred because the State Medicaid agency did not ensure that HCBS costs were allowable. Our review found that DMRS: (1) did not have a billing system to allow for unplanned changes in services provided, (2) had no controls to ensure that services billed were actually provided, and (3) had no controls to limit the number of services billed to the specifications in the beneficiary’s plan of care.

We recommend that the State Medicaid agency:

• refund to the Centers for Medicare & Medicaid Services (CMS) the $6,982,530 estimated excess Federal reimbursement for State fiscal year 2003;

• direct DMRS to establish controls and procedures to:

o account for changes in the actual level of services provided, o ensure that claims are adequately supported, and o ensure that HCBS are rendered in accordance with the beneficiary’s plan of care; and • review its claims filed after our audit period and refund any overpayments identified. In its comments to the draft report, the State Medicaid agency did not specifically address our first recommendation to refund $6,982,530. With respect to the second and third recommendations, the State Medicaid agency agreed that additional oversight and controls were needed and said that it had increased its monitoring efforts to help ensure that proper controls and procedures were in place. The State Medicaid agency described implementing several new processes and procedures. It offered assurance that it had recouped overpayments identified for the period after our audit and had adjusted its claims for Federal financial participation accordingly.

The State Medicaid agency’s comments did not warrant any revisions to the results of our review or to our recommendations. We credit the State for taking corrective actions, but we continue to recommend that the State Medicaid agency refund to CMS the $6,982,530 estimated excess Federal reimbursement for State fiscal year 2003.

If you have any questions or comments about this report, please do not hesitate to call me, or your staff may contact George M. Reeb, Assistant Inspector General for the Centers for

Page 3 Kerry Weems

Medicare & Medicaid Audits, at (410) 786-7104 or through e-mail at George.Reeb@oig.hhs.gov , or Peter J. Barbera, Regional Inspector General for Audit Services, Region IV, at (404) 562-7750 or through e-mail at Peter.Barbera@oig.hhs.gov . Please refer to report number A-04-03-03026.

Attachment

Page 2 Mr. Darin J. Gordon

Direct Reply to HHS Action Official:

Mr. Roger Perez Regional Administrator Centers for Medicare and Medicaid Services, Region IV Department of Health and Human Services 61 Forsyth Street, SW., Room 4T20 Atlanta, Georgia 30303-8909

Department of Health and Human Services OFFICE OF INSPECTOR GENERAL

EMA DN

T ENNESSEE H O C OMMUNITY -B ASED M ENTAL R ETARDATION S ERVICES FOR J ULY 1, 2002, T HROUGH J UNE 30 2003

Daniel R. Levinson Inspector General

September 2007 A-04-03-03026

Office of I nspector G eneral http://oig.hhs.gov

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by the following operating components: Office of Audit Services The Office of Audit Services (OAS) provides all auditing services for HHS, either by conducting audits with its own audit resources or by overseeing audit work done by others. Audits examine the performance of HHS programs and/or its grantees and contractors in carrying out their respective responsibilities and are intended to provide independent assessments of HHS programs and operations. These assessments help reduce waste, abuse, and mismanagement and promote economy and efficiency throughout HHS. Office of Evaluation and Inspections The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide HHS, Congress, and the public with timely, useful, and reliable information on significant issues. Specifically, these evaluations focus on preventing fraud, waste, or abuse and promoting economy, efficiency, and effectiveness in departmental programs. To promote impact, the reports also present practical recommendations for improving program operations. Office of Investigations The Office of Investigations (OI) conducts criminal, civil, and administrative investigations of allegations of wrongdoing in HHS programs or to HHS beneficiaries and of unjust enrichment by providers. The investigative efforts of OI lead to criminal convictions, administrative sanctions, or civil monetary penalties. Office of Counsel to the Inspector General The Office of Counsel to the Inspector General (OCIG) provides general legal services to OIG, rendering advice and opinions on HHS programs and operations and providing all legal support in OIG’s internal operations. OCIG imposes program exclusions and civil monetary penalties on health care providers and litigates those actions within HHS. OCIG also represents OIG in the global settlement of cases arising under the Civil False Claims Act, develops and monitors corporate integrity agreements, develops compliance program guidances, renders advisory opinions on OIG sanctions to the health care community, and issues fraud alerts and other industry guidance.

EXECUTIVE SUMMARY

BACKGROUND Home and Community-Based Services Waiver Authority Tennessee’s State Medicaid agency oversees section 1915(c) waivers to provide home and community-based services (HCBS) to Medicaid beneficiaries with mental retardation and developmental disabilities. Under 1915(c) waiver authority, States can provide services not usually covered by the Medicaid program, as long as these services are required to keep a person from being institutionalized. Division of Mental Retardation Services Under a contract with the State Medicaid agency, the Division of Mental Retardation Services (DMRS) manages the HCBS waivers and contracts with local entities to provide HCBS to approximately 4,300 mentally retarded and developmentally disabled individuals in the community. From July 1, 2002, through June 30, 2003, the State Medicaid agency claimed Federal reimbursement of nearly $150.6 million in HCBS costs. OBJECTIVES Our objectives were to determine whether the State Medicaid agency claimed Federal reimbursement for HCBS that were adequately supported in the providers’ records and provided in accordance with the beneficiaries’ approved plans of care. SUMMARY OF FINDINGS Based on our sample results, we estimate that during State fiscal year 2003 the State Medicaid agency claimed approximately $11 million ($7 million Federal share) for HCBS that were not supported by provider records. Our sample of 200 claims found 38 claims for unallowable services totaling $42,945: • Thirty-four claims were for services that were billed at a higher level of care than was provided. • Five claims were for services that were not adequately supported to determine that the services were provided. • One claim was for services that exceeded the allowed level of care specified in the beneficiary’s plan of care.

The 34 claims for services billed at a higher level of care than was provided include 2 claims with multiple errors, thus the claims are also included in the other two error categories. The unduplicated claim count is 38. The remaining 162 claims were allowable. The Federal reimbursement for the unallowable claims occurred because the State Medicaid agency did not ensure that HCBS costs were allowable. Our review found that DMRS: (1) did not have a billing system to allow for unplanned changes in services provided, (2) had no controls to ensure that services billed were actually provided, and (3) had no controls to limit the number of services billed to the specifications in the beneficiary’s plan of care. RECOMMENDATIONS We recommend that the State Medicaid agency: • refund to the Centers for Medicare & Medicaid Services (CMS) the $6,982,530 estimated excess Federal reimbursement for State fiscal year 2003; • direct DMRS to establish controls and procedures to: o account for changes in the actual level of services provided, o ensure that claims are adequately supported, and o ensure that HCBS are rendered in accordance with the beneficiary’s plan of care; and • review its claims filed after our audit period and refund any overpayments identified. STATE’S COMMENTS In its comments to the draft report, the State Medicaid agency did not specifically address our first recommendation to refund $6,982,530. With respect to the second and third recommendations, the State Medicaid agency agreed that additional oversight and controls were needed and said that it had increased its monitoring efforts to help ensure that proper controls and procedures were in place. The State Medicaid agency described implementing several new processes and procedures. It offered assurance that it had recouped overpayments identified for the period after our audit and had adjusted its claims for Federal financial participation accordingly. The State’s comments are included in their entirety as Appendix C. OFFICE OF INSPECTOR GENERAL’S RESPONSE We credit the State for taking corrective actions. However, we continue to recommend that the State Medicaid agency refund to CMS the $6,982,530 estimated excess Federal reimbursement for State fiscal year 2003.

TABLE OF CONTENTS

INTRODUCTION ...................................................................................................................1

BACKGROUND ..........................................................................................................1 Medicaid Program................................................................................................1 1915(c) Waivers...................................................................................................1

OBJECTIVES, SCOPE, AND METHODOLOGY......................................................2 Objectives ............................................................................................................2 Scope....................................................................................................................2 Methodology ........................................................................................................2

FINDINGS AND RECOMMENDATIONS .........................................................................3

FEDERAL REQUIREMENTS AND WAIVER PROVISIONS .................................4

UNALLOWABLE HOME AND COMMUNITY-BASED SERVICES .....................4

Unallowable Costs Claimed.................................................................................4 Inadequate State Medicaid Agency Oversight of the Division of Mental Retardation Services’s Procedures and Controls ...........................5 Excess Reimbursements Related to Unallowable Costs Claimed ..................................................................................................5