oversight

Supplemental Security Income Overpayments to Medicaid Nursing Home Residents Can Be Reduced

Published by the Government Accountability Office on 1977-08-23.

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

                           DOCUMENT RESUME
 03365 -   A23735171

 Supplemental Security Income Overpayments to Medicaid Nursing
 Rome   esidents Can Be Reduced. RD-77-131; B-164031 (4). August
 23, 1977. 12 pp. + 2 appendices (3 pp.),.

 Report to the Congress; by Elmer B. Staatj,   Comptroller General.
Issue Aree- Income Security Programs: Program Monitoring and
     Administration (130).
Contact: Human Resources Div.
Budget Function: Income Security:    ulblic Assistance and ther
    Income Suppleients (604); Health: Nursing      omes (557).
Organization Concerned; Department of Health, Education, and
    Welfare; Health Care Financig Administration; Socil
    Security Administration.
Congressional Relevance: Fouse Committee on Ways and eans;
    Senate Committee on Finance; Congress.
Authority: Social Security Act, as amended (42 U.S.C.      382-1382f
     (Supp. V)). Social Security Amendments of 1972 (42 .S.c.
    1381 (Supp.   Y)). 20 C.F.R. 416.705.
          when recipients of Supplemental Security Income enter
 nursing homes, their payments should b reduced because     dicaid
 pays the cost of nursing home care. Findings/Conc.usions: In
 1975, overpayments of about $7.6 million were made to
recipients in California and Florida because the SocialSS!Security
 Administration (SSA) d   not know that the recipients had been
admitted to nursing homes. The majority of these overpayments
could have been prevented through timely reporting of nursing
home admissions. Social Security regulations require the
recipient, or person authorized to accept his payments, to
report admissions, but only 3% of admissions reviewed by GAD
were reported. The regulations do not establish other methods
for obtaining the information, Some SSA district offices, on
their own initiative, made informal arrangements with nursing
homes to report admissions, and with proper encouragement, this
was found to be an effective means of obtaining timely reports.
Recommendations: The Commissioner of SSA should: reqcire the
district offices to provide forms to nursing homes for reporting
admissions: and actively work with the nursing homes to obtain
timely reports. The Administrator of the Health Care Financing
Administration should have the States establish procedures
requiring nursing homes participating in the edicaid program
                                                                to
report admissions of recipients to district offices promptly.
(Author/HTW)
           REPORT TO THE CONGRESS

           BY THE COMPTROLLER GENERAL
v:"+ ".    OF THE UNITED STATES




          Supplemental Security Income
          Overpaymeits To Medicaid Nursing
          Home Residents Can Be Reduced
          Department of Health, Education, and Welfare
          Social Security Administration
          Health Care Financing Administration

          Admission to a nursing home should result in
          a reduction of Supplemental Security Income
          benefits because the indiidual's care is pro-
          vided under the Medicaid program. Supple-
          mental Security Income overpayments, how-
          ever, are made because the Social Security
          Administration is not aware of recipient
          admissions to nursing homes. In California
          and Florida these overpayments amounted to
          $7.6 million during 1975. Social Security's
          reliance on recipients to report admissions has
          not been effective. Nursing homes are a good
          :-3urce of information on admissions, and
          UAO recommends hat they be used to report
          recipient admissions.




          HRD-77-131                                        AUGUST 23, 1977
               COMPTROLLIR GOINtEL OF THE U.ITO STATEI
                          WASHINGOTON, D.C.   0MI41




B-164031(4)



To the President of he Senato and the
Speaker of the House of Representatives

     The Social Security Administration needs more timely
reports of Supplemental Security Income recipients' admit-
tance to nursing homes. Accurate reporting information
would greatly reduce overpayments made to program recipi-
ents. Procedures should be developed to obtain such
reports from nursing homes.

     We made our review at te request of Senator Birch
Bayh. We are sending copies of this report to the
Director, Office of Management and Budget; the Secretary
of Health, Education, and Welfare; the Commissioner of
the Social Security Administration; and the Administrator
of the Health Care Financing Administration.




                                    Comptroller General
                                    of the Unite States
 COMPTROLLER GENERAL'S                SUPPLEME"TAL SECURITY INCOME
 REPORT TO THE CONGRESS               OVERPAYMENTS TO MEDICAID NURSING
                                      HOME RESIDENTS CAN BE REDUCED
                                      Department of Health, Education,
                                        and Welfare
                                      Social Security Administration
                                      Health Care Financing
                                        Administration

             L I G E S       T

             The Social Security Administration has nad
             many poblems in administering the Supple-
             mental Security Income program since it
             began in January 1974.  Social Security
             estimates, based on its quality assurance
             data, that it has overpaid Supplemental
             Security Income recipients about $600 mil-
             lion annually during the period July 1974
             tnrough June 1976.  This report is directed
             at overpayments to such recipients in
             nursing homes.  Under current law, the
             basic Federal Supplemental Security Income
             monthly payment for an individual is
             $177.80.  (See p. 1.,

             When a Supplemental Security Income recipient
             enters a nursing home for an expected stay
             of a full calendar month or longer, the pay-
             ments should be reduced to not more than
             $25 for each month of residence, because
             Medicaid pays the cost of nursing home care.
             The $25 is for personal and incidental ex-
             penses which are not covered by Medicaid.
             (See p. 3.)

             Supplemental Security Income overpayments
             are being made because Social Security often
             does not know that recipients have been
             admitted to nursing homes, and payments over
             $25 continue.   In California and Florida such
             overpayments amounted to $7.6 million during
             1975.  GAO estimates that the majority of
             these overpayments could have been prevented
             through timely reporting of nursing home
             admissions.   (See p. 4.)

             Social Security regulations make the re-
             cipient, or the person authorized to accept
             payments on his or her behalf, responsible
             for reporting nursing home admissions.       GAC's

Tear Shee. Upon removal, the report     i                   HRD-77-131
cover date should be noted hereon.
study showed hat these individuals reported
only 3 percent of admissions. (See p. 6.)
Social Security has no regulations for ob-
taining information on nursing home admis-
sions.   In several instances, Social Security
district offices, on their own initiative,
had made informal arrangements with nursing
homes to report admissions. These nursing
homes were an effective source for timely
reporting when provided frms to report
admissions and when frequent visits were
made to the homes to encourage prompt re-
porting;   (See p. 6.)
GAO recommends that the Secretary of Health,
Education, and Welrare direct the Commis-
sioner of the Social Scurity Administration
to (1) require the district offices to
provide forms to nursing homes for reporting
admissions and (2) actively work with the
nursing homes to obtain timely reports.
GAO also recommends that the Secretary direct
the Administrator of the Health Care Financ-
ing Administration to have the States estab-
lish procedures requiring nursing homes par-
ticipating in the Medicaid program to re-
port admissions of recipients to district
offices promptly.  (See p. 10.)
 she Department of Health, Education, and
Welfare enerally concurred with our con-
clusions and recommendations. However, the
Department commented that nursing homes
would report recipient admissions monthly
through a State agency rather than directly
to Social Security. This procedure would
not be acceptable because it would nt re-
sult in timely reporting of admissions to
Social Security. Timely reporting is cri-
tical to minimize overpayments which result
from failing to implemen. the reduced pay-
ment standard. (See pp. 11 and 4.)




                     ii
                           Contents

                                                           Page
  DIGEST
                                                                i
  CHAPTER

       1     INTRODUCTION                                       1
                 SSI program
                 Scope of review                                1
                                                                2
       2     NEED FOP TIMELY REPORTS O
               ENTERING NURSING OMES       RECIPIENTS
                                                            3
                 Entering a nursing home affects
                   payments                       SSI
                 Overpayments to nursing home               3
                   residents in 1975
                 Procedures for reporting nursing           4
                                                   home
                   residence                                6
                 Conclusions
                 Recommendations                            9
                                                           10
      3     AGENCY COMMENTS AND OUR EVALUATION
                                                           11
APPENDIX
      I     Letter dated May 20, 1977, from
                                             Thomas
              Morris, Inspector General, Department D.
              Health, Education, and Welfare         of
                                                           13
  II        Principal officials of the Department
              Health, Education, and Welfare      of
              for administering activities   responsible
              this report                  discussed in
                                                           15

                          ABBREVIATIONS
GAO         General Accounting Office
HEW         Department of Health, Education,
                                             and Welfare
SSA         Social Security Administration
SSI         Supplemental Security Income
                            CHAPTER 1
                          INTRODUCTION
      In August 1975 Senator Birch Bayh
                                        requested that we
 examine the Social Security Administration's
 ment of the Supplemental Security            (SSA's) manage-
                                   Income (SSI) program to
 determine wys of reducing SSI overpayments.
 second report on this subject. 1/             This is our

      During the period July 1974 through
 estimates, based on its quality assurance June 1976, SSA
 paid SS1 recipients about $600 million     data, that it over-
                                        annually.
 SSI PROGRAM
      The Social Security Amendments of
                                          1972 (42 U.S.C. 1381
 (Supp. II, 1972)) established the
                                    SSI program to replace the
 Federal grant-in-aid programs, administered
which provided assistance to the               by the States,
                                   aged, blind, or disabled
people with limited income and resources.
by SSA of the Department of Health,           SSI is administered
                                      Education,
 (HEW) and funded by the Federal Government,      and Welfare
mental benefits paid by the States.            except fot supple-
is mandatory if Federal payments       State supplementation
ments previously administered by  are  less  than program pay-
                                  the  States.   Additional
supplementation may be provided at
                                     the option of the States.
     In addition to being aged, blind,
individual's eligibility for SSI       or disabled, an
                                 is subject to certain income
and resource limitations. For example,
more than $1,500 ($2,250 for a couple)  an individual with
is ineligible.                         of countable resources

     Payment amount is dependent on living
are generally classified as independent      arrangements which
in the household of another, and         (in  own household),
current law, an eligible          in a nursing home. 2/ Under
                         individual with no countable income
and living independently receives
                                   a Federal SSI payment of
$177.80 a month ($266.70 for a couple).


1/Our first report, entitled "Supplemental
                                           Security Income
  Payment Errors Can Be Reduced," HRD-76-159,
  was also done at Senator Bayh's             Nov. 18, 1976,
                                  request.
2/The term nursing home as used in
                                   this report refers to a
  Medicaid (title XIX) skilled nursing
  facility.                            or intermediate care
     On January 1, 1974, SSA began making SSI payments to
about 3 million people converted from State and local pro-
grams. By December 1976, about 4.2 million people were
receiving SSI benefits. In the program's first 3 years,
over $13.1 billion in Federal funds and about $3.8 billion
of federally administered State supplemental funds were paid
to SSI recipients. States administering their own supplemen-
tal payments disbursed an additional $467 million during
this period.

SCOPE OF REVIEW

     The review was made in California, New York, and FloridP,
which account for alut 28 percent of the Nation's SSI reci-
pients.

     We evalutated SSA district office procedures for obtaining
reports on SSI recipients who enter nursing homes and the
timeliness of such reports. In California and Florida we
reviewed SSI and Medicaid paymenLs to nuLsing home residents
identified in a random sample of 1975 Medicaid billings. We
also drew a random sample of Medicaid billings from New York
City and 15 New York State counties for September and October
1975. This information was not useable, however, because of
insufficient centralized information on New York's Medicaid
program.




                              2
                          CHAPTER 2

                  NEED'FOR TIMELY REPORTS
            ON RECIPIENTS ENTERING NURSING HOMES
     In 1975 overpayments of about $7.6 million were made
to Supplemental SecurJiy Income recipients in California
and Florida because tht 'ocial Security Administration did
not know the recipients had been admitted to nursing homes.

     SSA regulations require the recipient, or his or her
authorized representative, to report changes in living
arrangements (such as adrttance to a nursing home) but
do not establish other methods for obtaining such information.
Recipients or their authe izod representatives have proven
to be unreliable in repolting such matters.

     Some SSA district offices in California have requested
nursing homes to report when SSI recipients are admitted.
Where appropriate contact and followup with the nursing home
was made by the district office, more timely information on
admittance of SSI recipients was obtained. We believe that
procedures should be developed to obtain such reports from
nursing homes nationally.

ENTERING A NURSING HOME AFFECTS-
SSI PAYMENTS

     The Social Security Act, as amended (42 U.S.C. 1382--
1382f Supp. V, 1975)), established maximum SSI payment
standards based on three living arrangements which are
illustrated in the following chart.




                              3
                          Payment standard including optional
               Federal       --- State supplementation (note a)
   Living      payment                                 Florida
arrangements   standard   California      New York     (note-b)
Independent    $177.80    $276.00         $228.65     $177.80
Household of
  aniother      118.54     220.07          120.05      118.54
Nursing home     25.00      25.00           25.00       25.00
a/Mandatory supplementation payments are made to some of
  the recipients who were on the State-administered programs
  at the time SSI became effective. Such payments are made
  on a case-by-case basis according to the recipient's
  benefit level under the former programs.

b/Florida pays no optional State supplementation to indivi-
  duals living independently or in the household of another.

     As shown above, entering a nursing home has the greatest
impac on the SSI payment amount. When a recipient becomes a
nursing home resident, his or her payments should be reduced
to not more than $25 for each calendar month of residence.
The reduced payment standard becomes effective with the re-
cipient's first full calendar month of residency in a nursing
home. The recipient's benefits are reduced because his room,
board, and medical attention are being provided under the
Medicaid program; $25 is for personal and incidental expenses.
Consequently, if SSA is not promptly notified of a nursing
home admission, substantial overpayments result because the
recipient's payment is based on a living arrangement other
than in a nursing home.

OVERPAYMENTS TO-NURSING
HOME RESIDENTS IN-T75

     To determine the impact of untimely or nonreporting of
nursing home admissions, we reviewed SI payments to nursing
home patients in California and Florida. In each State we
used a random sample from monthly Medicaid bills paid for
patients n nursing homes during 1975 and identified those
patients who had been issued SSI payments for the same month
as the bills. We then determined whether this payment was
correct, based on residing in a nursing home. The results
of our sample and projected SSI overpayments for the two
States are shown below.




                               4
                                       California     Florida
Number of 1975 Medicaid billings      765,025         175,137
Billings sampled                          581             626
Patients in sample:
    Receiving SSI                         191                104
    Overpaid SSI                           39                 23
SSI overpayment cases as a percentage
  of:
    Medicaid billings                     6.7            3.7
    SSI recipients                       20.4           22.1
Average SSI overpayments in the
  sample month                        $138.42         $81.13
Projected overpayments for SSI
  recipients in nursing homes in
  1975                             $7,100,000       $500,000
     Most of the recipients who were overpaid in the billing
month were also overpaid in previous or later months while
in the nursing home. On the average, recipients were over-
paid for about 7 months.
     While some overpayments are unavoidable due to the time
required to stop issuance of recipients' checks, a majority
of the projected $7.6 million overpayments for California
and Florida could ave been prevented thrugh timely reporting
of nursing home admissions.
     We also used a random sample from New York City and 15
New York State counties for September and October 1975 and
found that SSI recipients in nursing homes had been overpaid.
However, we were unable to project statewide overpayments
because of insufficient centralized information on the
State's Medicaid program.
     We were unable to project nationwide overpayments
because possible differences in the percent of the SSI
population entering nursing homes, differences in State
supplementation levels, and variances in SSA procedures
cause the rate of SSI overpayments to nursing home resi-
dents to change from State to State. However, SSA esti-
mates, based on its quality assurance data for the period
January through June 1976, that failure to reduce the pay-
rent standard for SSI recipients entering nursing homes
;esults in about $23 million annually in overpayments.



                            5
PROCEDURES FOR REPORTING
NURSING HOME RESIDENCE

     SSA regulations make the recipient, or the person
authorized to accept payments on his or her behalf, respon-
sible for reporting changes which affect SSI payment amount
or eligibility (20 C.F.R. 416.705). According to SSA pro-
cedures, the recipient is to be advised of this responsibility
at the time of initial entitlement to benefits and at least
once a year thereafter. The regulations do not establish
other methods or procedures for obtaining the information.

     We reviewed nursing home admissions in California, New
York, and Florida to determine the effectiveness of recipient
reporting and the potential for developing alternate sources
of information about recipients entering nursing homes. Two
SSA district offices were selected in each State to deter-
mine when and how the offices obtained information that SSI
recipients had entered nursing homes. Our review included
64 of the 71 nursing homes within the selected district
offices' jurisdiction and all SSI recipients admitted to
these homes in January 1976 1/ who were still patients on
April 30, 1976--a total of 6 recipients.

     Our sample showed that recipients notified SSA of their
admission in only 2 of the 69 cases (3 percent).  In 14 of
the cases (20 percent), the SSA district office did not know
as of May 1, 1976, that the recipient had entered a home.
In the remaining 53 cases (77 percent), SSA was informed from
another source, as follows:

Source                Number of-cases            Percent
Nursing home             a/32                     46.4
Relatives                a/12                     17.4
Social worker               6                      8.7
Other                       3                     -4.3
    Total                  53                     76.8
a/Some of these reports may have been made at the recipient's
  request.



l/February 1976 admissions to nursing homes in the jurisdic-
  tion of one New York district office were included.



                                6
      We also reviewed these 53 cases to determine the
 timeliness with which the admission reports were submitted.
 In 15 cases (28 percent), reports were made within a
 of admission; in 17 cases (32 percent), reports were week
                                                       made
 from 33 to 89 days after admission; and the remaining
                                                        21
 cases (40 percent) were made between 1 week and 33 days.

     In each district office visited, the procedures
obtaining reports on admissions differed. Of the 15 for
made within a week of admission, 11 were made to SSA reports
                                                     dis-
trict offices within California.

     Several SSA district offices in California have requested
nursing homes to report the admission of SSI recipients
cause recipients generally do not do so. On their        be-
                                                     wn initia-
tive, several district offices, together with the Los
                                                       Angelis
County Council of Nursing Home Associations, designed
cial form to facilitate this reporting. In the two     a spe-.
                                                     California
offices reviewed, this was the procedure followed. Conse-
quently, 48 percent of admissions in our sample from
district offices were reported by the nursing homes.  these
                                                       The
reports were received an average of 6.6 days after admission.

     In one of the district offices in California, nursing
homes were contacted at least twice a month to assure that
SSI admissions were reported, as well as seeing to any
SSA or SSi benefit problems. Nursing home personnel wereother
very aware of the reporting form and the reporting procedures
to be followed. In this district office, 71 percent
                                                      of the
admissions were reported by the nursing homes. The longest
lapse between admission and the nursing home's report
                                                       was
16 days.

     Both SSA district offices reviewed
procedures for obtaining information on in New York had
                                        admissions of SSI
recipients to nursing homes, but neither was as effective
as California. Nevertheless, 67 percent of admissions
reported to the district offices visited in New York
                                                     were
reported by nursing homes. This information, however,
was received an average of 33 days after admission.

     According to officials of one district office
York, their procedure is based upon the fact that in New
                                                   nursing
home personnel know SSI recipients should not receive
                                                       pay-
ments over $25. Consequently, when nursing home personnel
become aware of overpayments they inform the SSA field
resentatives who visit the larger nursing homes about rep-
                                                       once
a week. Smaller homes, acting for the recipients,
the payments through the mail. One problem with thisreturn


                             7
 procedure is that SSA would become aware of an admittance
 a nursing home only if the recipient's payment is          to
                                                    forwarded
 to the nursing home from the recipient's previous address.
 In this district office, information on 80 percent
                                                     of admis-
 sions was received through this method.  However, informa-
 tion on 35 percent of admissions was obtained more
                                                     than
 30 days after admission.

      The managei of the other district office in New York
 stated that its procedure was based upon  field represen-
 tatives visiting nursing homes to assist in dealing
                                                      with
 social security or SSI benefit problems. During these
                                                          visits
 the field representatives request nursing homes to
                                                     send  SSA
 a letter upon admission of SSI recipients.   From this proce-
 dure, information on 40 percent of admissions was received.
 However, information on only 10 percent of admissions
                                                        was
 received within the eek of admission, and 20 percent
 the admissions reviewed were received over 60 days     of
                                                     after
 admission.

      The SSA district offices reviewed in Florida used re-
ports on SSI admissions to nursing homes obtained
                                                   from
State welfare workers.   However, the nursing homes report
the admission of all Medicaid patients to the State
                                                     welfare
workers; this is done so that the worker can authorize
Medicaid payments. Although SSA determines Medicaid
                                                      eligi-
bility for Florida SSI recipients, the State redetermines
Medicaid eligibility for all Medicaid patients admitted
                                                          to
nursing homes. Florida's Department of Health and
                                                    Rehabili-
tation Services, which administers the State's Medicaid
program, requires its welfare workers to notify SSA
                                                     when
a nursing home admission is an SSI recipient.

     The district offices reviewed in Florida had taken
steps to obtain reports on SSI recipient admissions
                                                     directly
from the State's nursing homes. Neither office, however,
had given priority to making nursing homes a reporting
source.  Thirty-eight percent of the admissions sampled
were reported by State welfare workers an average of
                                                      13 days
after admission.  In only 6 percent of admissions was
information obtaindA from the nursing home.

     Field representatives from one district office in
Florida occasionally visited nursing homes and provided
forms for reporting SSI admissions. A district office
official said that not enough emphasis had been placed
                                                        on
this system. Several nursing home administrators said
that the district office had not given them the forms.



                              8
      We talked with the district office managers
 and Florida about the potential for using           in New York
                                             a
 California, making frequent visits to nursing form as  used in
 ing the homes report admissions. District       homes,  and hav-
 agreed that such a system would work well.   managers  generally
 pressed, however, that some nursing homes     Concern was ex-
                                            may not cooperate.
      In our discussion with California nursing
 we found no reluctance to cooperate with SSA. home officials,
 ship and willingness to cooperate with SSA       The relation-
                                              was extremely good
 where SSA field representatives made frequent
                                                 visits to
 nursing homes, explained the need for information
                                                     on SSI
 recipients, and left formis for reporting admissions.

     The Health Care Financing Administration of
ment of Health, Education, and Welfare is          the Depart-
                                           responsible
developing Medicaid program policies, setting             for
                                                standards,
making sure of compliance with Federal legislatior            and
lations. / The Secretary of HEW, through              and  regu-
Financing Administration, requires nursing the Health Care
                                            homes to maintain
records and report information for the Medicaid
These records contain the information that        program.
reports on SSI admissions. We believe the   SSA  would  need in
                                            Secretary
require nursing homes to report the admission           should
                                                of SSI recipi-
ents to SSA.

CONCLUSIONS
     Overpaymen3 are being made because SSA does
that SSI recipients have been admitted to          not know
                                          nursing
Recipients or their authorized representatives     homes.
to be an unreliable source of such information. have  proven
establish other methods for obtaining timely      SSA  should
on SSI recipients entering nursing homes.     information
procedures would reduce overpayments in the Improved reporting
                                             SSI program.
     Nursing homes are a good source for reporting
pient admissions. Furthermore, they are             SSI reci-
                                          required to maintain
records containing the information SSA would
of SSI admissions. There are, however, no     need in reports
quiring that nursing homes report admissionsregulations re-
review showed that nursing homes were the     to SSA. Our
                                           most effective and
reliable source of this information, and can
                                              be required to

I/On March 8, 1977, the Secretary of HEW announced
  administrative responsibility for the Medicaid   that the
                                                 program
  was transferred from the Social and Rehabilitation
  to a new Health Care Financing Administration.     Service


                               9
report admissions with a minimal amount of effort on their
part.
     Nursing homes were the principal information source in
both California and New York. State social workers were a
major source in Florida, and hey received their infornation
from nursing homes.

     Nursing homes proved to be an effective source for
timely information when the SSA district office provided
forms to nursing homes to report admissions and when dis-
trict office personnel made frequent visits to the homes
to encourage prompt reporting.

RECOMMENDATIONS
     We recommend that the Secretary of HEW:

     -- Direct the Commissioner of the Social Security
        Administration to establish procedures requiring
        that SSA district offices provide forms to nursing
        homes for their use in reporting admissions and to
        actively work with the nursing homes to obtain
        timely reports.

     -- Direct the Administrator of the Health Care Financing
        Administration to have the States establish procedures
        requiring nursing homes participating in the Medicaid
        program to report the admission of SSI recipients to
        SSA district offices promptly.




                             10
                          CHAPTER 3
               AGENCY COMMENTS AND EVALUATION
     In a letter dated May 20, 1977, HEW expressed agreement
with our report and stated that the timeliness and quality of
reporting SSI recipient admissions to nursing homes can and
should be improved.

     HEW concurred with our recommendation that SSA should
establish procedures requiring that district offices provide
forms to nursing homes for their use in reporting admissions
and to actively work with the nursing homes to obtain timely
reports.

     SS% has rec-ntly revised a form which will gather infor-
mation trom recipients when admitted to or discharged from
a nursing home. SSA will supply this form to nursing homes.
The mailable forms will be stamped with the address of the local
SSA district office.

     HEW concurred in principle with our recommendation that
the Health Care Financing Administration have the States
establish procedures requiring nursing homes participating
in the Medicaid program to report the admission of SSI
recipients to SSA district offices promptly.

     HEW outlined the procedure to be followed by the nursing
homes. First, the States will have the nursing homes report
all SSI admissions to the "single State agency." Second, the
"single State agency" will report such information monthly to
the SSI regional office.

     We are not sure what HEW intended by this procedure.
Our recommendations were aimed at a single objective, that
is, to have SSA district offices supply nursing homes with
forms which the nursing homes could use to report SSI reci-
pient admissions to district offices. Our first recommenda-
tion intended that SSA prepare and distribute the required
form through its district offices. Since SSA has no respon-
siblity for nursing home action, our second recommendation
was that the Health Care Financing Administration require
the nursing homes to use the form.

     The procedure outlired by HEW could be interpreted as
having nursing homes report SSI recipient admissions directly
to the "single State agency" and SSA district offices through
use of the self-addressed form. This dual reporting system
is not what we intended, and we fail to see that it has any
real benefit, unless such information is for some reason


                             11
useful to the "single State agency." We would not object
this dual reporting if it did not delay reporting to     to
                                                     the
district offices.
     The procedure outlined by HEW could also be interpreted
as having nursing homes only report SSI recipient admissions
to the "single State agency," that is, nursing homes would
report admissions directly to district offices. We would not
find this procedure unacceptable.

      As our report illustrates, timely reporting of SSI reci-
pient admissions to district offices is critical to minimizing
 the amount of overpayments which result from failing to
                                                          imple-
ment the reduced payment standard. Due to the time required
to stop issuance of recipients' checks, some overpayments
unavoidable. The majority of overpayments can be avoided, are
however, if SSA is apprised of admissions as early as
                                                       possible.
      The procedure outlined by HEW for reporting admissions
only monthly would probably result in at least one month's
overpayment in every case. In addition, it would make
reporting admissions more untimely in those areas where,
pointed out in the report (see p. 7), district offices     as
                                                        and
nursing homes have reached agreements on their own, which
provide that nursing homes report admissions directly
                                                       to
district offices.

     We believe HEW should implement the procedure according
to our recommendations and require that nursing homes
                                                      report
SSI recipient admissions directly to SSA district offices.
We believe this procedure is the most effective and simplest
means for reducing the number of SSI overpayments which
result from failing to implement the reduced payment standard.




                            12
APPENDIX I
                                                             APPENDIX I



    0
    0".        DEPARTMENT OF HEALTH, EDUCATION, AND WELFARE
                           OFFICE OF THE SECRETARY
                             WASHINGTON, D.C.   2a0l




                                                           MAY 2 03971



    Mr. Gregory J. Ahart
    Director, Human Resources
      Division
    United States General
      Accounting Office
    Washington, D.C. 20548
   Dear Mr. Ahart:
   The Secretary asked that I respond to your request for our
   on your draft report entitled, "Supplemental Security Incomecomments
   payments to Medicaid Nursing Home Residents Can e Reduced." Over-
   enclosed comments respresent the tentative position            The
                                                       of the
   ment and are subject to reevaluation when the final version Depart-
                                                                of this
   report is received.
   We appreciate the opportunity to comment on this draft report
   its publication.                                              before

                                       Sincerely yours,


                                       Thomas D. Morris
                                       Inspector General
   Enclosure




                                  13
 APPENDIX I                                                    APPENDIX I

 COMMENTS OF THE DEPARTMENT OF HEAI.TH, EDUCATION, AND WELFARE ON
                                                                  THE
 GAO DRAFT REPORT ENTITLED, "SUPPLEMENTAL SECURITY OVEKPAYMENTS TO
 MEDICAID NURSING HOME RESIDENTS CAN BE REDUCED," DATED MARCH
                                                               11, 1977


 GAO Recommendation

     That the Social Security Administration establish procedures requiring
     its district offices to provide forms to nursing homes for their
                                                                      use
     in reporting admissions, and to actively work with the nursing homes
     to obtain timely reports.

 Department Comment

 We concur with this recommendation and are in    ':eamentwith the GAO that
 the timeliness and quality of reporting infor,    ,n can end should be
 improved.

 Form SSA-8150, "Repecting Events--SSI," recently revised and now
                                                                  being
printed, provides or the reporting of any evert affecting eligibility
or payments and contains specific questions concerning admissions
                                                                   to and
discharges froi nursing homes and other institutions. This form
                                                                  covers
a wider range o circumstances than the model form included in GAO's
report and, thus, should be more effective as an information gathering
mechanism. The district offices will be requ.red to supply these
                                                                   forms
with instructions for completing them to institutions in their
                                                                service
areas.

The use of this form on a national basis together with the instruction
and training to be provided to district and Regional office personnel
should lead to significant improvement in quality and timeliness
                                                                 of
reporting.

GAO Recommendation

    That the Secretary, HEW, direct the Administrator of the Health
                                                                     Care
    Financing Administration (HCFA) to have the States establish procedures
    requiring nursing homes participating in the Medicaid program to
                                                                      report
    the admission of Supplemental Security Income (SSI) recipients to
                                                                       the
    Social Security Administration district offices in a timely manner.

Department Comment

We concur in principle wit. the GAO recommendation and will require
                                                                    the States
under the provisions of 45 CF! 250.21 to have all nursing homes
                                                                participating
in the Medicaid program report 11l SSI admissions to the single
                                                                State agency.
Under the provisions of 45 CFR 205.60(a)(2), HCFA will require
                                                               the single
State agency to report monthly such information to the SSI Regional
                                                                    Office.




                                   14
APPENDIX II                                                APPENDIX II



          PRINCIPAL OFFICIALS OF-THEDEPARTMENT OF

                HEALTH-EDUCATION    -AND   WELFARE

                 RESPONSIBLE FOR-ADMINISTERING
              ACTIVITIES-DISCUSSED-IN THIS -REPORT

                                             --Tenure of office--
                                                  From           To
SECRETARY OF HEALTH, EDUCATION,
  AND WELFARE:
     Joseph A. Califano, Jr.               Jan.     1977   Present
     David Mathews                         Aug.     1975   Jan. 1977
     Caspar W. Weinberger                  Feb.     1973   Aug.  1975
COMMISSIONER OF SOCIAL SECURITY:
     James B. Cardwell                     Sept. 1973      Present
ADMINISTRATOR, HEALTH CARE
  FINANCING ADMINISTRATION:
     Don I. Wortman (acting)               Mar.    1977    Present
ADMINISTRATOR, SOCIAL AND
  REHABILITATION SERVICE:
     Don I. Wortman (acting)               Jan.    1977 a/Mar.   1977
     Robert Fulton                         June    1976   Jan.   1977
     Don I. Wortman (acting)               Jan.    1976   June   1976
     John A. Svahn (acting)                June    1975   Jan.   1976
     James S. Dwight, Jr.                  June    1973   June   1975



a/The administrative responsibility for the Medicaid program
  was transferred from the Social and Rehabilitation Service
  to a new Health Care Financing Administration on March 8,
  1977.




                               15