Corporate Compliance

OIG: State agency may be responsible for duplicate payments

Compliance Monitor, September 28, 2005

The Connecticut Department of Social Services may have overpaid as much as $1.8 million for home healthcare services, the OIG found in a recent audit.

In Connecticut, home healthcare is provided as a benefit in both the Medicaid and Medicare programs. The Connecticut Medicaid program reimburses providers for home healthcare services largely on a fee-for-service basis. The Medicare program, however, uses a home health prospective payment system that provides a lump sum payment for covered services. The objective of the audit was to determine whether the state agency made Medicaid overpayments to dual-eligible beneficiaries (i.e. beneficiaries of Medicare and Medicaid).

For federal fiscal years 2002 and 2003, the OIG identified 3,453 Medicaid claims totaling $1.8 million-including $900,000 in federal dollars-for home healthcare services that overlap, and for which the state may have duplicated reimbursement.

The OIG recommended that the agency

  • educate its provider community on proper billing practices

  • consider conducting prepayment edits of selected claims

  • work with a Medicare regional home health intermediary to develop controls

  • initiate action to recover the potential overpayments identified

    To complete the audit, the OIG

  • interviewed relevant state officials

  • consulted with CMS regional staff

  • evaluated the home healthcare oversight activities identified as potential overpayments through computer matching

  • discussed coverage policies and reimbursement procedures for the Medicare and Medicaid programs with provider personnel

  • examined billing and medical records

  • selected cases for review

  • Most Popular