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OIG Cautions Home and Community Based Service Programs: Non-Compliance Will Not Be Tolerated


August 13, 2012

As part of its ongoing effort to improve the quality of health care and eliminate Medicaid waste, fraud and abuse, the Office of the Inspector General (OIG) for the U.S. Department of Health and Human Resources issued its June 2012 report concerning its oversight of quality of care in home and community-based services (HCBS) waiver programs.[1]  While not specifically naming the state of Pennsylvania in its report, the OIG subsequently identified Pennsylvania as one of the three states with the most persistent problems relative to its compliance in home and community-based waiver programs.[2]

States participating in HCBS waiver programs must demonstrate that they have systems in place to show that: (1) each beneficiary must have a written service plan based on an assessment of the individual's needs; (2) each beneficiary must be served by qualified providers; and (3) each State must have necessary safeguards to protect the health and welfare of beneficiaries.[3][4]

According to the report, the OIG found that some States have no monitoring systems for service plans, qualified professionals and health and welfare assurances, while others had inadequate strategies to correct problems in these areas.  Centers for Medicare and Medicaid Services (CMS) officials explained that, although CMS has the authority to terminate programs when States do not meet assurances, it generally does not do so because these programs serve vulnerable beneficiaries who might be left without critical services.  Therefore, expect CMS to develop a broader array of approaches to ensure compliance with each of the assurances.

Given the OIG report, we can reasonably anticipate that the PA Department of Welfare, under Governor Corbett's administration, will consider or improve upon the following practices:

(1)  Reviewing service plans, perhaps multiple times throughout the year and assigning different experts to assess various aspects of the plans;

(2)  Selecting a sample of service plans to review to ensure that the services in the plan matched the Medicaid claims submitted for the beneficiaries;

(3)  Reviewing provider qualifications and conducting onsite visits with each provider before allowing the provider to enroll in the HCBS program;

(4)  Scheduling visits with beneficiaries and/or mailing surveys to them to assess their satisfaction with providers;

(5)  Tracking license expirations electronically;

(6)  Automatically decertifying providers who did not renew their licenses;

(7)  Systematically tracking and correcting incidents of alleged abuse, neglect and suspicious death; and

(8)  Coordinating with other State agencies, when necessary, to review and resolve cases in which beneficiaries' health and welfare were at risk.

The public and private sector is on notice that waste, fraud and abuse will not be tolerated.  Programs should try to be ahead of the curve in establishing best compliance practices.


[1] OEI-02-08-00170; See (Social Security Act § 1915(c))[Standard services include but are not limited to: case management (i.e. supports and service coordination), homemaker, home health aide, personal care, adult day health services, habilitation (both day and residential), and respite care.]

[2] http://articles.philly.com/2012-06-28/business/32442057_1_medicaid-waste-medicaid-program-medicaid-services

[3] 42 CFR § 441.302(a)(1) and (2)

[4] Oversight activities described in this section are found in two CMS guidance documents: Instructions, Technical Guide and Review Criteria for Applications for a § 1915(c) Home and Community-Based Waiver [Version 3.5] (January 2008), and Updated Interim Procedural Guidance for Conducting Quality Reviews of Home and Community-Based Services (HCBS) Waiver Programs (February 6, 2007).