oversight

Supplemental Security Income: Timely Data Could Prevent Millions in Overpayments to Nursing Home Residents

Published by the Government Accountability Office on 1997-06-03.

Below is a raw (and likely hideous) rendition of the original report. (PDF)

                 United States General Accounting Office

GAO              Report to Congressional Requesters




June 1997
                 SUPPLEMENTAL
                 SECURITY INCOME
                 Timely Data Could
                 Prevent Millions in
                 Overpayments to
                 Nursing Home
                 Residents




GAO/HEHS-97-62
      United States
GAO   General Accounting Office
      Washington, D.C. 20548

      Health, Education, and
      Human Services Division

      B-271862

      June 3, 1997

      The Honorable Nancy L. Johnson
      Chairman, Subcommittee on Oversight
      Committee on Ways and Means
      House of Representatives

      The Honorable E. Clay Shaw, Jr.
      Chairman, Subcommittee on Human Resources
      Committee on Ways and Means
      House of Representatives

      Recent growth in the Supplemental Security Income (SSI) program and
      approximately $1 billion in annual overpayments to SSI recipients have
      increased congressional interest in ensuring that SSI recipients receive only
      those benefits to which they are entitled. In 1996, about 6.6 million SSI
      recipients received about $24 billion in federal payments and $3 billion in
      state supplemental payments, and the maximum monthly SSI federal
      benefit for eligible individuals was $470. There were about 1.8 million
      individuals in nursing homes and other similar institutions having their
      care paid by Medicaid at a cost of about $39 billion in 1995, and contrary
      to law, some of them were continuing to receive their full SSI benefits. This
      usually occurs because the Social Security Administration (SSA), which
      administers the SSI program, is unaware that the individuals are in
      Medicaid facilities.

      Because of your concern that some SSI recipients in nursing homes and
      other medical treatment institutions may receive overpayments, you asked
      us to determine (1) the extent of such overpayments, (2) the success or
      failure of SSA actions in preventing and detecting these overpayments, and
      (3) the methods by which SSA can better prevent such overpayments.

      To answer these questions, we interviewed officials from the Health Care
      Financing Administration (HCFA), which is the U.S. Department of Health
      and Human Services (HHS) agency responsible for the Medicaid program;
      SSA headquarters in Baltimore, Maryland; 4 SSA regional offices; and 13
      field offices. We also visited with Medicaid agencies in five states
      (California, Florida, New York, Tennessee, and Texas) to collect
      information on their Medicaid data systems. In addition, we analyzed SSA
      data on detected overpayments caused when SSA was not notified in a
      timely manner of SSI recipients’ admissions to medical institutions. We also
      obtained Medicaid nursing home admissions data for December 1996 from




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                   New York and Texas to determine the number of SSI recipients recently
                   admitted to nursing homes in these states and potentially receiving
                   overpayments. To demonstrate the potential of an automated information
                   interface between SSA and state Medicaid agencies to help minimize
                   overpayments, we obtained Tennessee state Medicaid data on admissions
                   to nursing homes and other Medicaid facilities and matched that
                   information against the Supplemental Security Record (SSR), SSA’s payment
                   record for the SSI program. This showed those recipients who were
                   residing in nursing homes but who were still receiving full SSI benefits.
                   (See app. I for more information on our scope and methodology.)


                   SSA estimates that overpayments to individuals in nursing homes may
Results in Brief   exceed $100 million annually; however, the exact extent is unknown.
                   Despite SSA procedures to prevent overpayments, and recent legislation
                   designed to further help prevent these overpayments to SSI recipients in
                   nursing homes, we determined, based on SSA data, that it had detected
                   overpayments totaling $24 million to about 31,000 recipients in fiscal year
                   1995. Furthermore, in two states we visited, New York and Texas, we
                   determined that SSA may not have been aware of an additional 1,699 SSI
                   recipients recently admitted to nursing homes during a 1-month period
                   and potentially overpaid these individuals $515,714 in benefits during the
                   subsequent month alone.

                   SSA efforts to prevent these overpayments or detect them in a timely
                   manner have had little success. In many cases, recipients or their
                   representative payees1 did not report the change in living arrangements in
                   a timely manner. In addition, because of other work priorities, SSA field
                   representatives have not routinely contacted the over 23,000 U.S. nursing
                   homes to solicit their cooperation in notifying SSA of admissions of SSI
                   recipients, as SSA policies require. Furthermore, our analysis of SSA data
                   shows that overpayments to SSI recipients residing in nursing homes have
                   increased by nearly 13 percent since the October 1995 effective date of the
                   legislation that was designed to reduce overpayments. While the effect of
                   this legislation is difficult to determine because SSA does not have uniform
                   systems for either following up on admission notifications from nursing
                   homes or monitoring compliance with the law, it has likely been
                   diminished by limited SSA actions to enforce the reporting requirement and
                   the lack of a statutory penalty for nonreporting by nursing homes.
                   Moreover, SSA’s other processes to detect overpayments in a timely

                   1
                    Representative payees are individuals or organizations that receive checks on behalf of SSI recipients
                   who are unable to manage their own affairs. A representative payee is responsible for dispensing the
                   SSI payment in a manner that is in the best interest of the recipient.



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             manner have not been effective. SSA’s redetermination process does not
             always provide timely identification of individuals in nursing homes
             because redeterminations are typically conducted only once every 6 years.
             Also, SSA’s annual computer match with HCFA does not contain Medicaid
             data from all states; does not result in timely identification of admissions;
             and places a substantial, manual workload on field office personnel.

             SSA could more quickly detect overpayments by electronically obtaining
             nursing home admissions data directly from states to help identify recent
             changes in recipients’ living arrangements. SSA could then use an
             automated interface to automatically adjust the benefits of SSI recipients
             admitted to nursing homes who are ineligible for continuation of benefits
             due to temporary institutionalization and prevent the occurrence of
             overpayments for the ensuing months. In the states we visited, we found
             that the state Medicaid agencies can make these data available to SSA. SSA
             could use an existing data exchange system with states to obtain the
             needed data electronically. Additionally, we found that in the interim
             period, while some states prepare their automated systems to make the
             electronic exchange of data with SSA, states could provide SSA with tapes
             or paper listings of this information for SSA’s use in detecting
             overpayments. To identify the program improvements such an automated
             interface could potentially produce, we conducted a joint effort with SSA
             and the Tennessee Department of Health Services. Through this match, SSA
             identified $31,000 in overpayments to individuals who had been approved
             for nursing home admission during February 1996 that SSA had not
             previously detected. Furthermore, by identifying SSI recipients in nursing
             homes sooner, the match demonstrated the potential to prevent an
             additional 9 months or more of overpayments that would likely have
             occurred before SSA detected the nursing home admissions. SSA and state
             Medicaid officials told us that they are addressing privacy concerns that
             may arise from this automated match.


             The SSI program is the country’s largest cash assistance program for the
Background   poor and one of the fastest-growing federal entitlement programs. SSI
             benefits are available under title XVI of the Social Security Act to people
             who are aged, blind, or disabled and have limited income and resources.
             The total SSI benefit is based on the amount of income and resources the
             recipients report and are verified to have by SSA. The benefit consists of a
             basic federal payment and, in some cases, a state supplement.




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                      In cases where SSI recipients are expected to be permanent residents
                      throughout a full calendar month in Medicaid-certified medical treatment
                      institutions2 and Medicaid pays over 50 percent of the costs of that care,
                      the maximum SSI federal benefit is limited to $30 per month. The benefit
                      reduction is applicable beginning with the first full month of permanent
                      residence. If the admission is not reported promptly to SSA, a recipient may
                      receive more than he or she is entitled to in the months following
                      admission. In some cases, at the time of application for admission to a
                      nursing home, a physician preliminarily determines whether the individual
                      is expected to stay in the facility temporarily, and this information is
                      provided to the state Medicaid agency. The agency is responsible for
                      determining eligibility for Medicaid coverage of nursing home care.
                      Individuals may continue to receive their full monthly benefit for up to 3
                      months if a physician certifies that they are expected to be
                      institutionalized for 90 full calendar days or less and they demonstrate the
                      need to pay expenses to maintain their home or living arrangement to
                      which they may return upon discharge from the facility. Recipients have
                      until the day of discharge or the 90th day of institutionalization, whichever
                      is earlier, to provide the physician certification and statement of need. SSA
                      does not change the benefit amount until a determination is made of
                      whether the recipient’s nursing home stay will be temporary.

                      SSA attempts to prevent overpayments to nursing home residents by relying
                      on recipient self-reporting and maintaining contacts with nursing homes to
                      obtain admissions information. In addition to attempting to prevent
                      overpayments from occurring, SSA also uses its redetermination process, a
                      periodic review of SSI recipients’ financial eligibility, and an annual
                      computer match with Medicaid data provided by 28 states to HCFA to
                      detect and stop payments that have occurred. (See app. II for more
                      detailed information on SSA actions to prevent and detect overpayments.)


                      SSA’s Office of Program and Integrity Reviews (OPIR), which annually
Actual Extent of      conducts detailed examinations of a sample of cases to determine the
Overpayments Is       accuracy of benefit payments, estimates that overpayments to SSI
Unknown, but May      recipients in nursing homes may exceed $100 million each year. OPIR
                      identifies erroneous payments that would otherwise go undetected
Exceed $100 Million   because it reviews and verifies all nonmedical factors of payment
                      eligibility for a random sample of individuals currently receiving benefits.
                      For example, OPIR reviews include visits to institutions and recipients’

                      2
                       These include hospitals, nursing homes, psychiatric institutions, and intermediate care facilities for
                      the mentally retarded. For the purposes of this report, we will refer to these facilities as “nursing
                      homes.”



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                                 residences to verify living arrangements. These types of in-depth
                                 examinations on a small sample of cases are in contrast to the usual
                                 procedures used in SSA field offices. There, claims representatives rely
                                 primarily on recipients to self-report changes in status because, according
                                 to SSA, it would be cost-prohibitive for field offices to conduct the same
                                 in-depth examinations. As a result, many admissions to nursing homes go
                                 undetected.

                                 In contrast to OPIR’s estimate of potential overpayments of $100 million, we
                                 found that in fiscal year 1995 SSA detected overpayments totaling
                                 $24 million to about 31,000 SSI recipients in nursing homes. Detected
                                 overpayments averaged about $800 or about 2 months of benefits;
                                 however, SSA estimates that such overpayments can continue for up to 9
                                 months before they are detected. As shown in table 1, detected
                                 overpayments to SSI recipients in nursing homes in 1995 ranged from less
                                 than $500 to over $7,500. Our analysis of SSA’s overpayment data showed
                                 that 1,960 recipients received in excess of $2,500 in overpayments,
                                 including 386 who received more than $5,000.

Table 1: Range of SSA-Detected
Overpayments to Nursing Home     Amount of overpayment                  Number of recipients   Percentage of recipients
Residents in Fiscal Year 1995    $1-$499                                             17,701                        57.5
                                 $500-$999                                            6,074                        19.7
                                 $1,000-$2,499                                        5,043                        16.4
                                 $2,500-$4,999                                        1,574                         5.1
                                 $5,000-$9,999                                          383                         1.2
                                 >$10,000                                                 3                         0.1
                                 Total                                               30,778                      100.0
                                 Source: SSA’s Supplemental Security Record.




SSA Is Unaware of Some           We obtained nursing home admissions data for December 1996 from New
SSI Recipients Recently          York and Texas, two of the states that do not provide data to HCFA via the
Admitted to Nursing              Medicaid Statistical Information System (MSIS) and, therefore, are not
                                 included in the annual match with SSA. We determined that SSA paid
Homes                            $515,714 in benefits to 1,699 SSI recipients in the month following their
                                 admission to nursing homes. Because these individuals were
                                 institutionalized for a full calendar month, SSI payments to them after that
                                 time are overpayments unless the recipients receive continuation of
                                 benefits due to temporary institutionalization. According to SSA records at
                                 the time of our review, these individuals were still classified as having



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                            living arrangements other than institutionalization, indicating SSA may not
                            have been aware that they were in nursing homes. Thus, SSA would have
                            continued to erroneously pay them full benefits either indefinitely or until
                            SSA found out about the situation. These matches indicate both that
                            non-MSIS states have undetected overpayment situations and that they have
                            information readily available that SSA could use to minimize its SSI
                            overpayments to nursing home residents.


                            We found that SSA efforts to prevent and detect overpayments to residents
SSA Achieved Limited        in nursing homes have had limited success. SSA has not been able to
Success in Preventing       effectively prevent overpayments because some SSI recipients (or their
and Detecting               representative payees) are not reporting changes in living arrangements as
                            required, SSA field offices are not routinely contacting facilities to identify
Overpayments                SSI recipients residing in the facilities, and recent legislation requiring
                            nursing homes to notify SSA of admissions of SSI recipients has had little
                            effect. Likewise, additional efforts to detect overpayments have been
                            hindered by (1) redeterminations that may be too infrequent to identify
                            many institutionalized individuals in a timely manner and (2) an
                            incomplete and untimely computer match with HCFA.


Recipients and              SSA’s first line of defense against making overpayments to nursing home
Representative Payees Are   residents is reports from the SSI recipients themselves. However, our
Not Reporting Admissions    review of SSA records indicate that some SSI recipients or their
                            representative payees did not report changes in living arrangements as
as Required                 required. Of the 30,778 individuals in nursing homes that SSA determined
                            were overpaid in 1995, about 47 percent had representative payees while
                            institutionalized. In one region we visited, SSA found that almost 75 percent
                            of erroneous payments to individuals in nursing homes had been caused
                            by recipients or their representative payees failing to report changes in
                            living arrangements. Twenty-five percent of erroneous payments had
                            resulted from field offices not following procedures when determining a
                            recipient’s living arrangement.


SSA Field Offices Not       SSA field office representatives have not routinely contacted nursing homes
Routinely Obtaining         to solicit their cooperation in notifying SSA of admissions, as SSA policies
Admissions Data From        require. In October 1993, SSA established policies requiring all field offices
                            to work closely with the staffs of nursing homes to facilitate the flow of
Facilities                  information regarding the admission to nursing homes of SSI recipients. We
                            found that most field offices we contacted had not established working



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                            relationships with the facilities, and in some cases they were not even
                            aware of the facilities in their area of responsibility.

                            According to the field office personnel we interviewed, some nursing
                            homes have routinely notified SSA field offices of SSI recipient admissions;
                            however, field offices could not always account for the notifications
                            because some do not maintain a log or have standard procedures for
                            following up on notifications. We found that neither SSA headquarters staff
                            nor field office representatives routinely monitor facility notifications to
                            ensure follow-up.

                            Each field office manager establishes the office’s work priorities, and in
                            the offices we visited we found that the priority placed on following up on
                            facility notifications varied. We were told that facility notifications are
                            given much lower priority than work responsibilities that are monitored,
                            such as claims processing. In addition, both SSA field office representatives
                            and regional office representatives stated that some notifications would
                            not have been processed in a timely manner, or in some cases not at all,
                            because they had been misplaced or lost. We were unable to quantify the
                            number of untimely or unprocessed facility notifications because no
                            records of notifications have been maintained.


Effect of Recent            The effect that recent legislation3 requiring nursing homes to report
Legislation in Preventing   admissions to SSA has had in preventing SSI overpayments to nursing home
Overpayments Is             residents is difficult to determine; SSA does not have a uniform system for
                            following up on admission notifications from nursing homes or for
Questionable                monitoring compliance with the law. However, our analysis of
                            overpayment data and interviews with SSA headquarters and field office
                            officials indicate that the legislation has had little effect in preventing
                            overpayments. For example, the amount of detected overpayments to SSI
                            recipients in nursing homes has grown by 12.3 percent since the
                            October 1995 effective date of the legislation, increasing from $24 million
                            in fiscal year 1995 to $27 million in fiscal year 1996. In instances where
                            facilities had reported admissions of SSI recipients, the majority of the field
                            offices we visited had no system for documenting the receipt or
                            disposition of the admissions referrals to SSA. As a result, SSA has no data
                            on which to determine whether nursing homes are complying with the
                            law, and there is no assurance that field office claims representatives are
                            following up on all admissions notifications.


                            3
                             The Social Security Domestic Employment Reform Act of 1994 (P.L. 103-387, sec. 6, Oct. 22, 1994).



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                             The effectiveness of the law has likely been diminished by limited SSA
                             efforts to carry out the reporting requirement and the lack of a penalty for
                             nonreporting by nursing home administrators. SSA has not developed any
                             regulations establishing a uniform mechanism for nursing homes to report
                             admissions or revised its agency policies on coordinating with institutions
                             since enactment of the law. Instead, SSA efforts primarily focus on having
                             its 1,300 field offices maintain contacts and solicit information from the
                             over 23,000 U.S. nursing homes. SSA has publicized the nursing home
                             reporting requirement and HCFA has issued notices to nursing home
                             administrators informing them of their reporting responsibilities. The
                             legislation, however, does not have a penalty for nonreporting by nursing
                             home administrators, and the amount of reimbursement nursing homes
                             receive for treating Medicaid patients is not affected by reporting or not
                             reporting; therefore, SSA must rely on voluntary compliance by nursing
                             homes. In 1995, SSA requested that HCFA develop and implement
                             procedures for monitoring compliance with the reporting requirement. To
                             date, neither SSA nor HCFA has developed such a system.


Often Redeterminations       SSA uses its redetermination process to verify that recipients remain
Have Not Identified          financially eligible for SSI payments and are receiving the correct amounts.
Institutionalized            However, because of resource constraints, SSA reviews the eligibility of
                             most recipients only once every 6 years. SSA records indicated that in 1995,
Individuals in a Timely      4,792 of the 30,778 overpaid individuals had redeterminations while they
Manner                       were in nursing homes. We found that 3,099 individuals each had one
                             redetermination, 352 had two, and 60 had three or more. According to SSA
                             records, 364 of these redeterminations involved face-to-face contact
                             between an SSA field office employee and the recipient or the
                             representative payee. Because of the infrequency of some
                             redeterminations, SSA cannot rely on this process to routinely and
                             effectively identify in a timely manner overpayments due to nursing home
                             residency.


Current Computer Match       Although SSA’s computer match with state Medicaid data from HCFA results
With HCFA Is Incomplete,     in about $4 million in program savings each year, it only contains data
Not Timely, and Results in   from 28 states, identifies overpayments only after they have continued for
                             a lengthy period, and places an unnecessary work burden on field offices.
Unnecessary Field Office     SSA does not independently obtain Medicaid nursing home admissions data
Work                         from states not participating in MSIS. Consequently, admissions of SSI
                             recipients to nursing homes in the remaining states, unless self-reported,
                             are likely to go undetected for long periods.



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                      In addition, SSA’s computer match with HCFA is not timely. For example, in
                      June 1995 HCFA matched data on possible nursing home admissions
                      occurring between April 1, 1994, and March 31, 1995. The resulting match
                      cases were sent to SSA field offices in October 1995 to be included in their
                      annual workload.4 Based on our review of a sample of cases identified
                      using the match, we found that an average of 14 months elapsed from the
                      time an individual was admitted to a nursing home until SSA headquarters
                      notified the field office to review the person’s case. Furthermore, it took
                      field office representatives an additional 4 months before they reviewed
                      the cases and made changes, if necessary, to the benefit amount.

                      The match also incorrectly identifies many individuals as having changed
                      their living arrangement, therefore placing an unnecessary and
                      unproductive work burden on field offices. Field office officials told us
                      that many of the match cases they review result in no changes in
                      recipients’ living arrangements or benefit amounts. We analyzed a sample
                      of 1996 MSIS match cases sent to field offices at the beginning of the fiscal
                      year and found that as of the close of the year, SSA field offices had not
                      completed reviews of 141 (28 percent) of the 503 cases in our sample.
                      About 28 percent of the completed cases were erroneously selected for
                      review because the individuals were temporarily institutionalized and had
                      been granted a continuation of full benefits. Another 26 percent of the
                      completed cases identified individuals who did not require a change in
                      benefit amount. SSA officials are aware of the deficiencies in the match
                      selection criteria that result in temporarily institutionalized individuals or
                      those in nursing homes for less than a full calendar month being selected
                      for review. However, they have yet to change the criteria to only identify
                      individuals institutionalized for a full calendar month who have not been
                      granted a continuation of full benefits because of temporary
                      institutionalization.


                      Obtaining MMIS data on nursing home admissions directly from states and
Automated Interface   conducting an automated interface in accordance with laws and standards
Could Help Prevent    governing computer matching, privacy, and security could provide SSA
Overpayments          with the opportunity to prevent or detect erroneous payments more
                      quickly, without the use of SSA field office personnel, and could result in
                      program savings and reduced administrative costs. The cost and ease of
                      states making MMIS data directly available to SSA electronically will vary
                      depending upon the level of automation in each state. However, we have

                      4
                       Field office workloads consist of processing initial claims and completing postentitlement actions,
                      such as redeterminations, benefit recomputations, and address changes.



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discussed this with selected state Medicaid, HCFA, and SSA officials, who
agreed that such a data exchange would be both practical and desirable.

Currently, for those who do not self-report their nursing home admission,
our review of a sample of 1996 cases found that it takes an average of 14
months from the time an individual enters a facility until the overpayment
is detected using the annual computer match with HCFA data that are only
available from 28 states, and takes an additional 4 months for the benefit
amount to be reduced by SSA. By electronically obtaining nursing home
admissions data directly from state Medicaid agencies SSA could prevent
overpayments or detect them much sooner—1 to 3 months after they
begin—for all 50 states. For example, an automated interface could consist
of matching SSI payment data with monthly nursing home admissions data
from state Medicaid Management Information Systems (MMIS) obtained
using existing telecommunications lines.5 According to SSA and HCFA
officials, SSA could obtain the data directly from states by modifying
existing state data exchange agreements6 to make SSA the recipient agency
of state MMIS data on nursing home admissions.

A way to efficiently use state MMIS data on nursing home admissions would
be through an automated system. An individual identified in the data as
residing in a facility for a full calendar month and subject to a benefit
reduction could automatically be sent a notice generated by computer
explaining the detection of a potential overpayment situation, the potential
revised payment amount, criteria for receiving the continuation of benefits
if the recipient is temporarily institutionalized, and the process for
appealing the benefit reduction. Following a reasonable response time
period to provide due process, the computer could, in appropriate cases,
automatically adjust the SSI benefit to the correct amount for the
appropriate months’ payments. Field office claims representatives would
not have to review the case or manually input changes to the recipient’s
payment file in order to correct the benefit amount. This would minimize
the time period over which the overpayment occurs, thereby saving
program dollars, and would reduce field office time devoted to this
activity, freeing it for other purposes. In those cases in which individuals
requested, and were determined to be eligible for continuation of benefits

5
 These lines, known as the File Transfer Management System (FTMS), already exists between SSA
headquarters and the states. SSA installed FTMS so that it could transmit SSA data on its clients to
every state. State agencies are required by the 1984 Deficit Reduction Act to use this information to
better identify those who are not eligible for public assistance or who are receiving incorrect benefits.
6
 At least monthly, SSA makes available to all states SSI eligibility and payment information to assist
them in administering SSI state supplemental payments and other federally funded programs such as
Medicaid and food stamps.



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                            due to temporary institutionalization, SSA could manually input changes to
                            the recipients’ files, overriding the automatic benefit reduction and
                            thereby continuing uninterrupted full benefit payments. Such an
                            automated system would require testing on SSA’s part to ensure the
                            reliability of state data for making automatic payment reduction decisions
                            and to minimize the risk of inappropriate reductions.

                            Some states have already demonstrated their capability to share data with
                            SSA to prevent and detect overpayments. Currently, the SSI payment file is
                            matched with data from the 28 states participating in MSIS. Furthermore, in
                            1994, SSA began establishing direct connections between its field offices
                            and states that had automated databases that could be easily linked to
                            SSA’s computer system. Currently, 15 states have entered into agreements
                            allowing SSA field offices to directly access certain state databases
                            containing information SSA can use to verify recipients’ reported income
                            and other factors of financial eligibility.

                            State Medicaid and SSA field office officials we interviewed said that SSA’s
                            routinely obtaining nursing home admission data directly from states
                            could provide the best opportunity to prevent or detect overpayments to
                            SSI recipients in nursing homes. Three of the states we visited do not
                            participate in MSIS, but the Medicaid officials in these states said that they
                            can make nursing home admissions data available to SSA electronically.
                            Tennessee has already made various state databases available for use by
                            SSA field offices. New York and Texas are negotiating with SSA to establish
                            pilot projects granting SSA access to certain state databases.


Pilot Match With            To help demonstrate the feasibility of SSA’s directly obtaining state
Tennessee Demonstrates      Medicaid nursing homes’ admissions data and more quickly detecting
Feasibility and             overpayments, we coordinated a joint effort between SSA and the
                            Tennessee Department of Health Services to identify SSI recipients in
Effectiveness of Directly   nursing homes. On the basis of data we obtained from Tennessee and
Obtaining State Data        provided to SSA, SSA detected $31,000 in overpayments to 40 SSI recipients
                            from February to July 1996. These recipients had not previously been
                            identified by SSA as residing in nursing homes. The overpayment amounts
                            ranged from less than $10 to almost $1,800, and the average overpayment
                            was $775. In addition to detecting overpayments, the pilot allowed SSA to
                            prevent at least 9 months of additional overpayments to individuals that
                            would likely have gone undetected and that SSA would not have been likely
                            to collect. The pilot match in Tennessee, a state that accounts for about
                            3 percent of all SSI recipients, demonstrates that by directly obtaining state



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                               data, SSA could not only more quickly identify SSI recipients in nursing
                            MMIS
                            homes, but also prevent future overpayments.


SSA Currently Conducts      SSA already conducts routine automated computer interfaces with the
Automated Interfaces With   Department of Veterans Affairs, the Office of Personnel Management, and
Some Federal Agencies       the Railroad Retirement Board that result in automatic benefit reductions
                            without SSA field office involvement. In each of these interfaces, SSR and
                            files from the source agencies are matched. When the match determines
                            that an individual on both the SSR and the source agency file are the same
                            person and there has been a change in income affecting the SSI benefit, the
                            system automatically adjusts the benefit and generates a notice to the
                            recipient about the revised payment amount. Before any benefit reduction
                            occurs, a recipient has 10 days after receiving notification of the benefit
                            change to file an appeal and continue receiving unreduced benefits,
                            otherwise the benefit reduction occurs automatically, without a field
                            office representative reviewing the case. SSA estimates that these
                            interfaces result in about $41 million in program savings each year.


SSA and States Have Taken   Certain privacy and security concerns may arise when data are exchanged
Actions That Address        electronically between agencies. These concerns center on ensuring that
Privacy and Security        personal information that an individual provides to one government
                            agency is protected from being disclosed to other agencies that do not
Concerns Raised by          have a legal right to it. Granting SSA direct access to state Medicaid data
Electronic Data Exchanges   will not violate the privacy rights of individuals who provide this
                            information because SSA will simply electronically obtain information to
                            which it already has a legal right. SSA already obtains this information from
                            28 states using HCFA’s MSIS data.

                            As part of its procedures to determine whether to implement electronic
                            data exchanges with state agencies, SSA assesses the costs, benefits, and
                            security risks of conducting such exchanges. According to SSA officials, an
                            automated computer interface between SSA and state MMIS would be
                            subject to the same procedures and feasibility testing prior to nationwide
                            implementation. Although we did not evaluate the effectiveness of SSA’s or
                            the states’ security procedures, SSA and state officials told us that these
                            procedures will be stringent enough so that SSA can obtain state data
                            electronically and conduct automated interfaces without compromising
                            confidentiality. SSA and states have taken steps specified in federal security
                            standards that, we were told, would ensure the confidentiality and security
                            of data exchanged electronically. These include instituting written



                            Page 12                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
                             B-271862




                             agreements between SSA and state agencies regarding how the data will be
                             used and using computer lines dedicated solely to the transmission of data
                             between government agencies.


States Can Provide Data to   In the interim period, while states are preparing to make the necessary
SSA in Other Formats         nursing home admissions data directly available to SSA electronically, they
While Preparing to Make It   could provide SSA with tapes or paper listings of admissions to nursing
                             homes. SSA could use this information to detect overpayments sooner than
Available Electronically     it can using data from the current annual computer match. In the states
                             that we contacted during our review, state officials told us that providing
                             this information to SSA routinely would require only minimal computer
                             programming to format the data for SSA’s use. Two states we visited, New
                             York and Texas, provided this information to us on computer tapes so that
                             we could identify previously undetected potential overpayments to
                             nursing home residents in those states.


                             Generally, SSI benefits are supposed to be reduced for those individuals in
Conclusions                  nursing homes for more than a full calendar month when Medicaid is
                             paying the cost of care. For many years, however, SSA has lacked an
                             effective process to prevent SSI recipients in nursing homes from receiving
                             overpayments. It has relied primarily on (1) inadequate self-reporting by
                             recipients, (2) inconsistent and irregular field office contacts with nursing
                             homes, (3) untimely redeterminations, and (4) an incomplete computer
                             match with Medicaid data from HCFA that does not result in timely
                             identification of nursing home admissions. Neither SSA’s efforts nor the
                             recent legislation requiring nursing homes to report admission of SSI
                             recipients to SSA has been fully effective. As a result, SSA continues to
                             overpay millions of dollars to thousands of recipients in nursing homes.
                             Given SSA’s experience that only about 15 percent of outstanding
                             overpayments to SSI recipients are collected, it is important that SSA detect
                             these overpayments as soon as possible and prevent future overpayments.

                             HCFA  has the authority to require states to make available to SSA MMIS
                             information on nursing home admissions. States would be paid 90 percent
                             of the costs of developing the necessary capabilities and 75 percent of the
                             operating costs. Our efforts with three states have shown that directly
                             obtaining state MMIS data could help SSA prevent or more quickly detect
                             overpayments and simultaneously reduce the SSA field office workload. In
                             the interim, while such arrangements are being made, states could provide
                             tapes or hard copies of these data to SSA to help control its payments, with



                             Page 13                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
                         B-271862




                         minimal effort or cost to the states. Preventing or detecting erroneous
                         payments more quickly and decreasing SSA’s reliance on recipients and
                         nursing homes to report changes in circumstances that affect eligibility
                         would bolster the integrity of the SSI program by helping ensure that
                         clients are receiving only those benefits to which they are entitled and
                         would save both program and administrative costs.


                         To prevent overpayments to SSI recipients in nursing homes or detect them
Recommendations          sooner, we recommend that the Secretary of Health and Human Services
                         direct the Administrator of HCFA to require states, as part of MMIS systems
                         requirements, to include information on nursing home admissions as
                         standard data elements in their MMIS and make these data elements
                         available to SSA electronically, in accordance with the laws and standards
                         governing computer matching, privacy, and security.

                         We also recommend that the Commissioner of SSA take the following
                         actions:

                     •   Establish agreements with the states to routinely obtain state MMIS data on
                         nursing home admissions electronically, as soon as feasible.
                     •   Establish interim agreements with state Medicaid agencies, while states
                         adapt their systems to make this information available to SSA
                         electronically, to obtain computer tapes or paper listings of admissions to
                         nursing homes and use this information to identify overpayment situations
                         and begin recovery actions and payment reductions.
                     •   Determine the reliability of state MMIS data for purposes of supporting
                         automatic benefit reductions for those SSI recipients identified as residing
                         in nursing homes for a full month who are not eligible for continuation of
                         full benefits due to temporary institutionalization and, if the data are
                         reliable, implement a system for automatic benefit reduction.


                         In commenting on a draft of this report, SSA agreed that improvements can
Agency Comments          be made in obtaining and processing nursing home admissions data on SSI
and Our Evaluation       recipients (see app. III). SSA noted that it has been working on solutions to
                         this problem, including obtaining MSIS data, which are submitted
                         voluntarily by 28 states, from HCFA. Acknowledging that MSIS data do not
                         cover all admissions, SSA is working with HCFA to determine if HCFA’s new
                         system, the Resident Assessment Instrument System (RAIS), can be used to
                         identify SSI recipients in nursing homes in a more timely manner. The
                         primary purpose of collecting the assessment information is to help



                         Page 14                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
B-271862




nursing home staff plan and evaluate the care they provide to residents.
SSA said that should RAIS not prove feasible, it would then consider the
recommendations in our report.

We have no objection to SSA’s use of RAIS, if in fact it is the most effective
and efficient way of reducing SSI overpayments to nursing home residents.
However, while RAIS may provide SSA with the data it needs to more
quickly identify SSI recipients in nursing homes, we have several significant
concerns in this regard. First, not all states participate in RAIS. While HCFA
has instructed all Medicare- and Medicaid-certified nursing facilities to
complete the assessment on all residents upon admission, currently HCFA
does not require that the assessment results be submitted to it or any other
entity. According to HCFA officials, HCFA will require all states to participate
in RAIS as part of the President’s fiscal year 1998 budget proposal to create
a separate prospective payment system for nursing homes. HCFA officials
told us that they do not know whether this proposal will be adopted.
However, contrary to SSA’s comments on our report, HCFA already has the
authority to require all states to make nursing home admissions data
available to SSA using state MMIS, as we suggested in this report.

Second, we are concerned about the reliability of the RAIS data in
identifying whether Medicaid is paying for the nursing home care, which is
a key factor in determining whether a recipient’s SSI benefit amount is
affected by residency in a nursing home. According to HCFA officials,
facilities’ nursing staffs would most likely be completing the assessments
and may not be familiar with the source of payment for the residents. If
the nurses do not accurately complete the source of payment information
on the assessment forms, SSA would be matching its file with erroneous
payment data from RAIS. The MMIS information we recommend that SSA use
is treatment authorization or paid claims data already approved by the
state Medicaid agency.

A third issue concerning RAIS is timeliness. RAIS is still being piloted and,
according to HCFA officials, may not be fully operational in all states at
least until summer 1998, which would allow the current level of related SSI
overpayments to continue for over a year. SSA stated in its comments on
this report that MMIS data would be available only quarterly. However, MMIS
data can be provided monthly or even more frequently if sent from the
states directly to SSA. Consequently, we continue to believe that
electronically obtaining nursing home admission data directly from states
provides SSA with the best opportunity to detect nursing home admissions




Page 15                     GAO/HEHS-97-62 Overpayments to Nursing Home Residents
B-271862




more quickly than its current efforts and also to prevent additional
overpayments.

In the interim, while SSA determines whether RAIS is the best solution for
identifying SSI recipients in nursing homes, we believe that obtaining MMIS
data directly from states each month through computer tapes or paper
listings is preferable to the delays experienced under SSA’s current
procedures. The states we contacted said that they could format the data
for SSA’s use and provide data to SSA on a monthly basis. Furthermore, two
states we visited demonstrated that nursing home admissions data could
be made available by providing us with computer tapes that allowed us to
identify previously undetected potential overpayments.

Finally, SSA said that it is highly questionable that a system for automatic
benefit reduction can be implemented because of the in-depth information
required to determine whether a recipient is eligible for continued benefits
due to temporary institutionalization. As we stated in the report, the
benefit reduction would occur only after automated notices were sent to
recipients asking if they resided in the nursing home for more than a full
calendar month and the appropriate due process procedures were
followed. For those recipients requesting a continuation of benefits, the
automated reduction would be suspended, and SSA would then follow its
current procedures for determining eligibility for continued benefits. Only
the benefits of those recipients remaining in nursing homes and not
requesting a continuation of benefits would automatically be reduced
without field office review.

In commenting on a draft of this report, HHS noted HCFA’s willingness to
provide the MSIS data it now receives from the states to SSA on a quarterly
rather than annual basis. (See app. IV.) This suggestion fails to recognize
the underlying reason for our specific recommendation. Having HCFA
involved in the pass-through of information between the states and SSA
causes both an unnecessary expense for HCFA and a timeliness delay for
SSA. The SSI program needs access to nursing home admissions data as
quickly as possible after the actual admissions to minimize the
overpayments it makes. Consequently, we continue to believe that the
most effective data transfer is directly between the states and SSA on as
frequent a basis as possible.

HHS also commented about the need to offset the costs associated with our
recommendation for each state and for HCFA against the benefits to be
derived by the SSI program. We agree. As stated in this report, we were told



Page 16                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
B-271862




by both officials of the states we visited and knowledgeable officials in
HCFA that only minimal computer programming would be required to
format the data for SSA’s use. It should also be noted that the federal
government would pay 90 percent of the developmental costs and 75
percent of the operating costs for operating such a data exchange system,
thereby further reducing the burden of this change on the states. The
minimal costs associated with developing and operating such a system,
including those incurred by SSA, should be compared with the tens of
millions of dollars in reduced overpayments to the SSI program that our
work indicates would accrue. Moreover, if our recommendations are
adopted, HCFA will no longer be asked to provide MSIS data to SSA, thereby
saving HCFA the costs it currently incurs.

Finally, HHS suggested that we also investigate using the RAIS database as
another alternative to our recommendation. As stated in our response to
SSA’s comments on this report, it is unknown when all states will
participate in contributing data on nursing home admissions to RAIS, and
the reliability of this system for identifying whether Medicaid is paying for
the nursing home care is questionable. This information is paramount to
determining whether an SSI overpayment has been made.

SSA and HHS also made other technical comments, which we incorporated
throughout the report as appropriate.


We are sending copies of this report to relevant congressional committees;
the Director, Office of Management and Budget; the Commissioner, SSA;
the Secretary of Health and Human Services; and other interested parties.
Copies will also be made available to others on request. If you or your staff
have any questions concerning this report, please call me on
(202) 512-7215. Other GAO contacts and staff acknowledgments are listed in
appendix V.




Jane L. Ross
Director, Income Security Issues




Page 17                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Contents



Letter                                                                                            1


Appendix I                                                                                       20

Objectives, Scope,
and Methodology
Appendix II                                                                                      22

SSA Actions to
Prevent and Detect
Overpayments
Appendix III                                                                                     25

Comments From the
Social Security
Administration
Appendix IV                                                                                      29

Comments From the
Department of Health
and Human Services
Appendix V                                                                                       33

GAO Contacts and
Acknowledgments
Table                  Table 1: Range of SSA-Detected Overpayments to Nursing Home                5
                         Residents in Fiscal Year 1995




                       Page 18                 GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Contents




Abbreviations

FTMS       File Transfer Management System
HCFA       Health Care Financing Administration
HHS        Department of Health and Human Services
MMIS       Medicaid Management Information System
MSIS       Medicaid Statistical Information System
OPIR       Office of Program and Integrity Reviews
RAIS       Resident Assessment Instrument System
SSA        Social Security Administration
SSI        Supplemental Security Income program
SSR        Supplemental Security Record


Page 19                 GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix I

Objectives, Scope, and Methodology


              To determine the extent of overpayments to individuals because they
              resided in nursing homes, we reviewed the Supplemental Security Record,
              the Social Security Administration’s payment record for the Supplemental
              Security Income program. We obtained fiscal year 1995 and 1996 data and
              identified those individuals SSA determined had been paid erroneously
              because of institutionalization in nursing homes. We analyzed the payment
              record and developed aggregate information on overpaid recipients.

              To determine the success or failure of SSA’s actions in preventing and
              detecting overpayments, we interviewed SSA headquarters officials in
              Baltimore, Maryland; 4 regional offices; and 13 field offices. In addition to
              these discussions, we analyzed the SSR to determine the effectiveness of
              SSA’s match with the Health Care Financing Administration. Of the 5,907
              fiscal year 1996 Medicaid Statistical Information System match cases sent
              to the field offices for review, we identified the 503 cases that appeared in
              SSA’s 10-percent sample data files. These files are random samples of all
              cases in a given month on the SSR. SSA field offices had completed reviews
              of 362 of the 503 cases as of the end of the fiscal year. We obtained and
              analyzed payment history data for the completed cases to determine the
              outcome of SSA’s matching effort.

              Finally, to determine methods by which SSA can better prevent
              overpayments, we interviewed state Medicaid officials in five states to
              obtain information about Medicaid data systems to determine the
              feasibility of conducting an automated interface with SSA. We selected
              Tennessee because of its advancements in providing electronic access to
              the state’s information systems. We selected the other four states
              (California, Florida, New York, and Texas) because they have the four
              largest SSI populations, accounting for almost 40 percent of the total SSI
              population. We obtained Medicaid nursing home admissions data for
              December 1996 from New York and Texas and matched it against the SSI
              payment file to identify SSI recipients admitted in that month to nursing
              homes in these states and the resulting potential overpayments. Moreover,
              we coordinated a pilot between SSA and the Tennessee Department of
              Health Services to further document the feasibility of SSA’s directly
              obtaining state Medicaid data. Tennessee officials provided data on all
              individuals in Tennessee approved for admission to nursing homes in
              February 1996 and paid claims data from February through July 1996. We
              used these data to determine the length of nursing home stays. We
              provided this information to SSA and had SSA systems analysts develop a
              computer program to compare Tennessee’s admissions and paid claims




              Page 20                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix I
Objectives, Scope, and Methodology




data with SSR data to identify SSI recipients who had received
overpayments because they resided in nursing homes.

Since SSR and the state Medicaid information systems are subject to
periodic quality assurance reviews, we did not independently examine the
computer system controls for them. Except for this limitation, we
conducted our review between April 1996 and April 1997 in accordance
with generally accepted government auditing standards.




Page 21                        GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix II

SSA Actions to Prevent and Detect
Overpayments

                        SSA  requires that recipients report entrance into nursing homes as quickly
SSA Relies on           as possible. However, because many recipients do not report this
Reporting by            information, SSA also establishes working relationships with nursing
Recipients and          homes to obtain admission and discharge information on the SSI
                        population. Furthermore, legislation was enacted, effective in
Nursing Homes to        October 1995, to require that nursing homes provide this information to
Prevent                 SSA.

Overpayments            At the time of application for benefits, claims representatives in SSA field
                        offices inform SSI recipients that they are required to report information
                        that may affect their eligibility or payment amounts. If the recipient has a
                        representative payee, the payee is responsible for reporting such
                        information to SSA. Significant events to be reported include a change in
                        income, resources, marital status, or living arrangements, such as
                        admission to or discharge from a nursing home. Failure to report such
                        changes can result in monetary penalties of up to $100 per event.

                        Although SSI recipients are the primary source for reporting changes in
                        their living arrangements, SSA recognizes that recipients entering nursing
                        homes may not always report their admissions on a timely basis, if at all.
                        Therefore, SSA attempts to obtain admission and discharge information
                        directly from nursing homes. In October 1993, SSA instructed its field
                        offices to work closely with nursing homes to facilitate the flow of
                        information regarding the admission of SSI recipients. Field offices are to
                        maintain ongoing contact with all appropriate institutions in their service
                        areas, use regular visits as a means to encourage cooperation, and
                        establish procedures for institutions to make timely reports on events that
                        affect SSI recipients’ eligibility and benefit amount. Also, the Social
                        Security Act, as recently amended, states that the Commissioner of SSA
                        must require each administrator of a nursing home to report within 2
                        weeks any admission occurring on or after October 1, 1995, of any eligible
                        individual or eligible spouse receiving SSI benefits. The legislation was
                        designed to prevent overpayments to SSI recipients who failed to report
                        their admission to nursing homes. To comply with the legislation, SSA and
                        HCFA notified nursing home administrators of the reporting requirement.
                        The law, however, did not contain a penalty for nonreporting by nursing
                        home administrators.


                        In addition to relying on recipient self-reporting and contacts with nursing
SSA Actions to Detect   homes to prevent overpayments, SSA uses its redetermination process and
Overpayments Once       an annual computer match to detect such payments once they have
They Have Been Made     occurred. A redetermination is a review of financial eligibility factors to


                        Page 22                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix II
SSA Actions to Prevent and Detect
Overpayments




ensure that recipients are still eligible for SSI payments and are receiving
the correct amount. A redetermination addresses financial eligibility
factors such as income, resources, and living arrangements and can be
conducted by mail, telephone, or face-to-face interview. Given its limited
resources, SSA conducts redeterminations on over two-thirds of the SSI
population receiving benefits approximately once every 6 years but may
conduct them more frequently if it determines that changes in eligibility or
erroneous payments are likely. Recipients with a history of recent earnings
are likely to be redetermined more often than recipients, such as
institutionalized individuals, who generally do not experience fluctuations
in their income or resources. The redetermination procedure includes a
question for recipients about whether the recipient spent a full calendar
month in a hospital, nursing home, other institution, or any place other
than the recipient’s normal residence. With this question, SSA hopes to
identify situations where overpayments to recipients may have occurred.

SSA  has conducted an annual computer match with HCFA since 1992 to
identify SSI recipients in nursing homes. Currently, SSA sends a file to HCFA
containing identifying information on all SSI recipients residing in the 28
states that provide data to HCFA via the Medicaid Statistical Information
System (MSIS). The MSIS file contains Medicaid usage data submitted by
states on a voluntary basis. HCFA matches the MSIS nursing home
admissions data with the SSA file to identify SSI recipients who resided in
nursing homes during the period covered by the match and sends a file to
SSA with this information. After reviewing the match results, SSA deletes
cases in which individuals (1) have self-reported their admission to SSA,
(2) are not in current pay status, or (3) are deceased. SSA then distributes
information on potential overpayment situations to the appropriate field
offices during October of each year. According to SSA procedures, field
office representatives are to contact the recipients or nursing homes
during the balance of the fiscal year to determine if overpayments have
been made. SSA does not begin overpayment recovery efforts until
recipients are discharged from facilities and are eligible to receive their
full SSI benefit.

Although SSA uses the MSIS data from 28 states to help detect
overpayments, Medicaid data from all states exist and could be used by SSA
more frequently than once a year. Generally, nursing homes report
admissions of individuals and file claims for reimbursement with state
Medicaid agencies in a timely manner to ensure rapid payments from
Medicaid to them. States use automated systems, known as Medicaid
Management Information Systems (MMIS), to process claims and to capture



Page 23                        GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix II
SSA Actions to Prevent and Detect
Overpayments




and report data needed by HCFA and the states to manage the Medicaid
program. The Secretary of Health and Human Services has broad authority
to require states to report data that HCFA needs to administer the Medicaid
program. State MMIS must meet performance standards as well as system
and compatibility requirements established by HCFA. HCFA requires each
state’s MMIS to include 122 standard data elements and pays 90 percent of
the development costs and 75 percent of the operating costs of these
systems.




Page 24                        GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix III

Comments From the Social Security
Administration




               Page 25   GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix III
Comments From the Social Security
Administration




Page 26                       GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix III
Comments From the Social Security
Administration




Page 27                       GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix III
Comments From the Social Security
Administration




Page 28                       GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix IV

Comments From the Department of Health
and Human Services




              Page 29   GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix IV
Comments From the Department of Health
and Human Services




Page 30                      GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix IV
Comments From the Department of Health
and Human Services




Page 31                      GAO/HEHS-97-62 Overpayments to Nursing Home Residents
               Appendix IV
               Comments From the Department of Health
               and Human Services




Now on p. 9.




Now on p. 4.




Now on p. 9.




               Page 32                      GAO/HEHS-97-62 Overpayments to Nursing Home Residents
Appendix V

GAO Contacts and Acknowledgments


                  Roland H. Miller III, Assistant Director, (202) 512-7246
GAO Contacts      George A. Scott, Evaluator-in-Charge, (202) 512-5932


                  In addition to those named above, the following individuals also made
Acknowledgments   important contributions to this report: Mary Ellen Fleischman, Evaluator;
                  James C. Lawson, Evaluator; Graham D. Rawsthorn, Evaluator; John G.
                  Smale, Jr., Senior Social Science Analyst; and James P. Wright, Assistant
                  Director (Study Design and Analysis).




(106809)          Page 33                    GAO/HEHS-97-62 Overpayments to Nursing Home Residents
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