The United States Department of Health and Human Services Office of the Inspector General (“OIG”) conducted an audit of New York State’s nonhospital-based Continuing Day Treatment (“CDT”) program.
CDT services are clinic services administered by the New York State Office of Mental Health (“OMH”). OMH’s CDT program provides Medicaid recipients with treatment designed to maintain and/or enhance current levels of functioning and skills, to maintain community living, and to develop self-awareness and self-esteem through the exploration and development of strengths and interests. CDT services include, but are not limited to, assessment and treatment planning, discharge planning, medication therapy, case management, psychiatric rehabilitation, and activity therapy.
To be eligible for the CDT program, a recipient must have a diagnosis of a designated mental illness as well as a dysfunction due to a mental illness. The recipient’s treatment plan must be completed in a timely manner; be signed and approved by both the recipient and the physician involved in the treatment; include a diagnosis of a designated mental illness, treatment goals, objectives, and related services, a plan for the provision of additional services, and criteria for discharge planning; and be reviewed every 3 months. Additionally, progress notes must be recorded at least every 2 weeks by the clinical staff members who provided CDT services to the recipient. The progress notes must identify the particular services provided and the changes in goals, objectives, and services, as appropriate. In addition, CDT services must be adequately documented, including type, duration, and need for continuing services.
The OIG audit report alleges that New York State claimed federal Medicaid reimbursement for nonhospital CDT services that did not comply with federal and State requirements. Of the 100 claims in the OIG’s random sample, 66 claims complied with federal and State requirements, while 34 claims allegedly did not. The audit period was from April 1, 2009 to August 17, 2011.
According to the OIG audit report, the alleged deficiencies occurred because (1) certain nonhospital CDT providers did not comply with federal and State regulations and (2) the State did not ensure that OMH adequately monitored the CDT program for compliance with certain federal and State requirements. On the basis of the sample results, the OIG estimated that the State improperly claimed at least $18,093,953 in federal Medicaid reimbursement for nonhospital CDT services that did not meet federal and State requirements.
The OIG recommended that the State refund $18,093,953 to the Federal Government; work with OMH to issue guidance to the provider community regarding federal and State requirements for claiming Medicaid reimbursement for nonhospital CDT services; and work with OMH to improve OMH’s monitoring of the CDT program to ensure compliance with federal and State requirements.
According to the OIG audit report, New York State responded as follows
. “In written comments on our draft report, the State agency disagreed with our first recommendation (financial disallowance) and did not indicate concurrence or nonconcurrence with our remaining recommendations. Specifically, State agency officials stated that we based our findings entirely on State regulations and, if OMH found claims to have violated the State regulations we cited, those violations “would not have rendered the services non-reimbursable.” The State agency also disagreed with our determination that, for one sampled claim, progress notes were not prepared by a staff member who provided a service. Specifically, State agency officials stated that, for the sampled claim (#73), a progress note clearly demonstrated that “the treatment provider was actively engaged” with the beneficiary during the 2-week period that included the sampled service date. In addition, the State agency disagreed with our determination that certain sampled claims did not meet reimbursement standards. State agency officials indicated that their preliminary analysis of our workpapers revealed that providers supplied us with schedules of group services that beneficiaries were scheduled to attend each day they visited the CDT provider. State agency officials stated that these schedules document the frequency and types of services planned for each beneficiary.”
As a result of the OIG audit, it is likely that the New York State Office of the Medicaid Inspector General (“OMIG”) will be conducting additional audits of CDT providers.
The OIG audit report is available at http://oig.hhs.gov/oas/reports/region2/21201011.pdf.
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 email@example.com.