The state of New Jersey has falsely claimed at least $94.8 million in Medicaid reimbursement over the last four years, according to a new report from the HHS' Office of Inspector General.
The OIG found that the New Jersey Department of Human Services didn't comply with federal and state requirements regarding reimbursement for its Medicaid Partial Care Services Program. The program provides outpatient clinical services to Medicaid beneficiaries with serious mental illness as a way to reduce unnecessary hospital admissions.
The OIG examined a random sample of 100 claims for partial care services from 2009 to 2012. The agency found that 92 of the claims didn't comply with federal and state requirements for reimbursement.
Nicole Brossoie, a spokeswoman for the New Jersey Department of Human Services, said, “The department disputes the audit's findings and has responded accordingly in an addendum to the auditor's report.”
Brossoie also noted that the OIG audit report still awaits a review from the CMS and it will determine necessary repayment.
In their written response to the report, department officials said the OIG's recommendation that the $94.8 million be refunded to the federal government was “unwarranted.”
The state added that much of the alleged noncompliance relates to state requirements rather than federal requirements, and therefore the state should not have to refund the CMS.
The department also argued that the OIG imposed unreasonable documentation standards on providers in order to comply with requirements, calling it a “hyper-technical approach.” The state department argued that providers should have the flexibility to provide services based on their professional judgment.
The OIG disagreed with both arguments and concluded that the New Jersey Department of Human Services didn't “adequately monitor” the program to ensure compliance among providers.
Eighty-four of the 92 false claims found by the OIG were not appropriately documented or supported. The agency found that although it is required, services provided were often not included in the beneficiary's care plan and documents didn't include detailed explanations of how specific therapies and activities were appropriate for the individual.
The OIG also discovered that 20 of the 100 claims examined didn't provide a written agreement between a clinic and the supervising physician, as mandated by state law.
Along with refunding the CMS for its false claims, the OIG also recommended the state health agency improve its monitoring of the program and issue guidance to providers on requirements for compliance of the program.
Overall, improper billing to Medicaid accounted for $36.25 billion in fiscal 2016, according to HHS' most recent financial report.