Objective

To determine the extent of implementation of the 11 recommendations made in our initial audit report, Improper Medicaid Payments for Recipients in Hospice Care (2017-S-76).

About the Program

Hospice is a program that provides care to terminally ill individuals, with a focus on easing symptoms rather than treating the disease. Generally, when eligible Medicaid recipients elect hospice care, they waive their right to use Medicaid for curative services and a hospice organization assumes responsibility for all medical care related to the terminal illness. Medicaid reimburses hospice organizations an all-inclusive daily rate that covers all hospice services. However, if a Medicaid recipient is also enrolled in Medicare, Medicare is the primary payer and Medicaid is the secondary payer. In these cases, Medicaid generally pays the dual-enrolled recipients’ cost-sharing obligations of copayments, deductibles, and coinsurance.

We issued our initial audit report on December 11, 2018. The audit objective was to determine whether Medicaid made improper payments to providers on behalf of recipients receiving hospice care. The audit covered the period January 1, 2013 through December 3, 2017. Our audit identified over $8 million in improper Medicaid payments for medical services provided to recipients receiving hospice care. Many of the overpayments occurred because the Department of Health (Department) did not have a process to identify and track Medicaid recipients receiving hospice care. Consequently, the eMedNY claims processing system did not have controls to prevent payments to non-hospice providers for services that were non-allowable or duplicative or when hospice claims should have been covered by other insurance. We recommended that the Department review the improper payments we identified and make appropriate recoveries; implement a process to identify recipients receiving hospice care; determine what services are disallowed in conjunction with hospice services and update Medicaid policy manuals and all providers of the changes; and implement controls to prevent future improper payments.

Key Finding

Department officials did not make much progress in addressing the problems identified in the initial audit report, and significant action is still required to prevent future Medicaid overpayments. Of the initial report’s 11 audit recommendations, 1 was implemented, 3 were partially implemented, and 7 were not implemented.

Key Recommendation

Officials are given 30 days after the issuance of the follow-up report to provide information on any actions that are planned to address the unresolved issues discussed in the follow-up report.