Medicaid provider overpaid $4.9M

Staff Report

Columbus – A Medicaid examination of Great Nursing Care, Inc. (Franklin County) found the home health agency was overpaid $4.9 million because it provided services with unqualified employees and billed for services before obtaining proper authorization.

The overpayment is the largest amount identified in a Medicaid examination since Auditor Yost took office in 2011.

Auditors found 553 errors in a statistical sample of 1,283 services provided between July 1, 2011 and June 30, 2014, resulting in overpayments totaling $4,960,320. The provider received a total of $12,059,215 in reimbursements during the period. With $257,053 in interest, Great Nursing Care, Inc. owes the Ohio Department of Medicaid $5,217,373.

Auditors tested 80 aides for compliance with Medicaid requirements and determined that 62 lacked first aid certification, making them ineligible to provide services. Of the 18 aides who were certified, 12 had lapses at some point during the examination period and were therefore ineligible at those times.

Auditors also concluded that 42 of 43 aides hired during the examination period were ineligible because they failed to fulfill all requirements of the initial competency evaluation. A separate review of in-service continuing education requirements revealed that 12 of 16 aides tested completed less than 10 of the required 12 hours in 2012 and 11 of 20 tested did the same in 2013, making them ineligible. Auditors noted a total of 396 services provided by ineligible aides.

“These are requirements – not guidelines,” Auditor Yost said last year. “This provider could have avoided much of this mess if it had ensured all employees were properly trained and billed for services only after receiving a physician’s authorization for service.”

During a review of service authorization, auditors found 115 errors in the statistical sample, including 86 services submitted for reimbursement before the provider obtained a physician’s signature on the plans of care and 22 services that had no plans of care.

Additionally, auditors noted 69 errors with service documentation in the statistical sample, including 57 services that lacked supporting documentation and 10 instances where the units billed exceeded the units documented.

After receiving a draft examination report, the provider informed auditors that it had ceased operations. During an exit conference on Aug. 16, 2016, the owners stated they had taken steps to ensure continuity of care by connecting all recipients with another home health agency. That agency, which hired many of the provider’s employees, agreed to be the custodian of the provider’s medical records.

A full copy of this report is available online.

Top Overpayments to Home Health Agencies Since January 2011

Provider Name, County, Amount

Great Nursing Care, Inc., Franklin, $4.96M

Shifo Healthcare Services, LLC, Franklin, $2.06M

Total Home Health Care, Inc., Franklin, $1.50M

Accent Care, Pickaway, $1.20M

Amandacare, Inc., Franklin, $767K

Staff Report

Information for this story was provided by the Auditor of State’s office.

Information for this story was provided by the Auditor of State’s office.