NCJ Number
69014
Date Published
1979
Length
18 pages
Annotation
WHEN 242 BILLS FOR MEDICAID REIMBURSEMENT SUBMITTED BY THE OFFICE OF MENTAL HEALTH (OMH) TO THE NEW YORK CITY DEPARTMENT OF SOCIAL SERVICES WERE REVIEWED, IT WAS FOUND THAT ONLY 21.5 PERCENT WERE VALID.
Abstract
OUTPATIENT TREATMENT RECORDS FOR FEBRUARY 1978 AT FIVE OMH-OPERATED PSYCHIATRIC CENTERS IN NEW YORK CITY (BRONX, CREEDMORE, KINGSBORO, MANHATTAN, AND SOUTH BEACH) WERE REVIEWED TO DETERMINE IF THEY HAD SUFFICIENT DOCUMENTATION TO SUPPORT RESULTING MEDICAID BILLINGS. TO BE ELIGIBLE FOR MEDICAID REIMBURSEMENT, THE CLIENT MUST HAVE RECEIVED A BILLABLE TREATMENT ON THE DATE CLAIMED, BE UNDERGOING AN ADEQUATE TREATMENT PLAN, AND BE UNDER THE CARE OF A PHYSICIAN. SINCE ONLY 21.5 PERCENT OF THE BILLINGS EXAMINED WERE VALID, THE STATE COULD LOSE OVER $2.5 MILLION IN FEDERAL AND CITY MEDICAID FUNDS IN 1978. FULLY 62.4 PERCENT OF THE RECORDS EXAMINED LACKED DOCUMENTATION (PROGRESS NOTES ON THE CLINICAL CHART) THAT THE CLIENT RECEIVED TREATMENT ON THE DATE SHOWN. TREATMENT PLANS WERE LACKING IN 14 PERCENT OF THE CASES. NO SUPERVISORY NOTES OR EVIDENCE OF PHYSICAL REVIEW WAS FOUND IN 45 PERCENT OF THE CASES. SIMILAR DEFICIENCIES WERE NOTED IN OTHER DOCUMENTATION REQUIREMENTS. RECOMMENDATIONS TO IMPROVE CONDITIONS INCLUDE STAFF EDUCATION ON THE NECESSITY OF COMPLETE MEDICAL RECORDS AND PROCEDURES FOR IMPLEMENTING OMH STANDARDS AND MANUAL, A REVIEW OF THE RECORDS FOR THE PERIODS NOT YET AUDITED AND THEIR COMPLETION, AND INTRODUCTION OF PERIODIC AUDITS OF TREATMENT RECORDS IN ORDER TO ASSURE COMPLIANCE. FURTHER EXAMINATION OF ALL OTHER CLINIC VISITS THE MONTH FOUND THAT ONLY 78 PERCENT WERE BILLED TO THE SOCIAL SERVICES, CAUSING THE STATE TO LOSE ABOUT $900,000 ANNUALLY. RECORDS FOR AT LEAST THE PAST 2 YEARS SHOULD BE EXAMINED AND BILLS PROCESSED. EXHIBITS INCLUDE TABLES SHOWING RECORDS DEFICIENCIES. AN APPENDIX DETAILS THE SEQUENCE OF EVENTS IN THE ATTEMPT TO GAIN OMH'S FORMAL REPLY TO THE DRAFT REPORT. (TAG)