Payments Made in Error for Personal Care Services During Institutional Stays

摘要

To determine (1) the extent to which five State Medicaid programs made payments in error for personal care services (PCS) during periods of beneficiary institutionalization and (2) what controls these States reported establishing to prevent those payments. PCS provide the elderly, people with disabilities, and individuals with chronic or temporary conditions with the assistance that they need to remain in their homes or communities. State Medicaid programs may reimburse the cost of PCS for individuals who are not inpatients or residents of certain institutions but should not separately reimburse for personal care services furnished during institutional stays. We reviewed Medicaid PCS and institutional claims and Medicare institutional claims for services provided from October 1 through December 31, 2005, in five States: Minnesota, New Mexico, North Carolina, Texas, and Washington. During the period of our review, these States paid a total of $11.6 million for 29,057 claims for PCS that overlapped with the dates of institutional stays. We compared the dates of service for paid PCS claims with the dates of service for paid Medicaid and Medicare institutional stays to identify Medicaid payments for PCS provided during institutional stays. We also interviewed State Medicaid officials about the reasons the identified claims were paid and their efforts to prevent such payments.