NJ – OIG Report Reveals Improper Medicaid Payments

January 2017 ~

A report released by the HHS Office of Inspector General (OIG) states, over a four-year span, New Jersey has received an estimated $95 million in improper Medicaid payments.

According to the report, “The deficiencies occurred because the state … did not adequately monitor [its] partial care services program to ensure that providers complied with [the program’s] requirements,” which resulted in providers not complying with CMS requirements for Medicaid reimbursement.

New Jersey’s health department claimed about $272 million ($136 million in federal share) in Medicaid reimbursement for over 3.8 million partial care services claims between 2009 and 2012. However, the OIG reported, a random sample of Medicaid claims for partial care claims from that period revealed that most claims did not comply with federal and state reimbursement requirements.

Out of 100 claims, 92 claims were found to be non-compliant. Of these claims the OIG found the following deficiencies:

  • 84 claims contained services not documented or supported
  • 20 claims had no physician affiliation agreement
  • 6 claims did not meet care plan requirements
  • 4 claims did not have weekly progress notes documented
  • 1 claim did not meet intake assessment requirements
  • 19 claims contained more than one deficiency for Medicaid reimbursement

To resolve the falsely claimed Medicaid reimbursement, the OIG suggests that the state agency refund the federal government for partial care services claims that did not meet federal and state requirements for payment.

As well the OIG recommended that the state’s health department develop guidance for the partial care provider community which focuses on federal and state requirements for Medicaid reimbursement. The OIG says New Jersey’s health department should also “improve its monitoring of partial care providers to ensure compliance with Federal and State requirements,” OIG continued.

In response, New Jersey DHS disagreed with the OIG’s repayment recommendation, citing “unreasonable documentation standards on providers.” NJ DHS told OIG that providers should have more flexibility with furnishing appropriate services based on their professional judgement and not be limited to the services outlined in beneficiary care plans.


Source(s): RevCycle Intelligence; Modern Healthcare; NJ Spotlight; OIG;