DCCJENT BESIUHE , 03757 - [B2914159] * R/a(/~/ (Delays in ReimburseLent for Home Health Services in New York City]. ERD-78-8; B-164031(3, . October 17, 1977. 6 pp. Report to Rep. Benjamin S. Rosenthal; by Gregory J. Ahart, Director, Human Resources Div. Contact: Human Resources Div. Budget Function: Health: Health Care Services (551). Organizaticn Concerned: New fork, WY; Department of Health, Education, and Welfare; Health Care Financing Administration. Congressional Relevance: Rep. Benjamin S. Rosenthal. Authority: Social Security Act, as amended, title XIX (42 U.S.C. 1396). An audit was conducted of New York City's hose health care program by examining the reimbursement system n-ao by the Borough of Queens, with particular emphasis on identifying reasons for delays in paying for hcme attendant services. Findings/Conclusions: Twelve home attendant cases having problems makin- payments to home attendants on the regular 2-week basis were identified. Delays generally ranged between 1 and 3 months, although one 10-montb delay was attributed to a lost check. Some of delays were caused by the city and some by the clients' failure to report changes ia their status or the status of the home attendants. The most frequent cause of delay by the city involved slow reauthorization of beneficiary eligibili.y. New York City officials said they were aware of the delays and had proposed some procedural changes tn correct the problems. New program procedures are to bt implemented throughout the city and administrative changes such as centralizing the payment function and printing computer runs in a sore useful format will be implemented. (SY) RMSTRICTED - Not to be relesed outside the General ACeouDfntl Office eocept o,' the basis of specific approval by by) fft o GENERAL reit oe Coeng nfontlb tn~~ES CACCOUNTING OFFICE WASHINGTON, D.C. 20S5 HUMmA RnomwCm B*-164031(3) OCT 17 1977 The Honorable Benjamin S. Rosenthal Bouse of Representatives Dear r. Rosenthal, letter This is in response to your October 19, 1976, care pigrarm. New York City's home scope requesting us to auditoffice, we limited the of our As agreed with your by New system used work to a review of the reimbursement services, York City in tie Borough of Queens for home care with particular emphasis on identifying reasons for delays letter confirms in paying for home attendant services.in This our March 28, 1977, information presented to your office care program as briefing and describes the home health eplairned by key city officials in September 1977, by your We reviewed 12 home attendant cases identified found delays in and office as having reimbursement problemsSome delays were caused payment ranging from 1 to 10 months. or the client. by the city and some by the home attendant of these delays New York City officials said they were aware to correct and had' initiated or planned procedural changes some o- thle problems we identified. HOME ATTENDANT -PROGRAM New York City's home attendant program provides household services to aged and disabled chore, personal care, and other can be persons, often with little mobility. 7 days services These a week, for a authorized for up to 24 hours a day, procedure, maximum of 6 months. Through a reauthorization Services services can be provided as long as necessary. reimbursement provided under the program are eligible for for the needed under Medicaid when there is a medical basis by a registered services and the services are supervised nurseH ERD-78-B B-164031(3) Program administration The Medicaid program is authorized by title XIX of the Social Security Act, as amended (42 U.S.C. 1396). It is a grant-in-aid program through which the Federal Government pays from 50 to 78 percent of the costs incurred by States for providing medical servicee: to individuals unable to pay for them. The program is administered at the Federal level by'/te Health Care Financi..ng Administration within the Departm ,it of Health, Ed ~-ition, and Welfare. Each State has primary responsib.lity for administering its Medicaid program and must specify a single State agency to administer or supervise the administration of the program. In New York, the State Department of Soci L. Services super- vises program administration by local political subdivisions but retains overall program responsibility. The home attendant program in New York City is admin- istered by its Department of Social Services. Two separate offices within the department have primary responsibility for the program--the Office of Case Intake and Management and the Office of Family and Adult Services. The Office of Case Intake and Management, with various intake centers scattered throughout the city, is responsible for --receiving and processing initial applications for home care services and for continued case manage- ment, including reauthorization; 1/ -- obtaining documentation of a medical need before home attendant servicei can be authorized, and reevaluating the need before reauthorizing services! and l/Except for the Borough of Manhattan, where the Office of Family and Adult Services handles case management. 2 B-5,64031(3) -- forwarding the name(s) of possible attendants recommended by the clients and all other documen- tation relating to the case to the Office of Family and Adult Services for processing. The Office of Family and Adult Services is responsible for reviewing the documentation from the Office of Case and Management for completeness and accuracy; screening theIntake suggested home attendants or, if no individual attendant been recommended, referring a suggested home attendant has client for approvals and authorizing payment for services. the to Bone attendants are paid with two-party checks made payable to the attendant and the client. At the time of our fieldwork, these checks were issued by a number of different paying units. According to key city officials, in the fall of 1976 the city initiated a pilot project in Queens whereby all applica- tions for home care services were screened by a medical-social worker. This central unit, within the Office of Family and Adult Services, reviews each case to assure that the servi.es are necessary and appropriate. If extensive services are prescribed--over 30 hours s week--the case is referred to another unit for further review to determine whether savings are possible. This unit rev;,ews each c!ae for appropriateness of services, availability of other health insurance, feasibility of substituting less expensive services for those recommended, and other means to save money. In Queens, home attendants paid through a central office. We were told the pilot project are was initiated to tighten controls and improve the efficiency the Queens operation. of Program procedures The specific procedures for approving receive home care services and for approvingindividuals the to attendants vary from one borough of the city to another. The following procedures apply to the Borough of Oueens, although some are used in ot ier boroughs. Persons requesting home attendant services with a local Office of Case Intake and Managementmust apply center. To qualify, the person must (1) be eligible for public assistance or Medicaid and (2) have a documented medical need, certified by a physician. Eligibility must be periodically reauthorized. 3 B-164031(3) Sixty days before its service expiration date, a client's case is included in a comi:,uter listing of potential reauthor- izations, which is to be forwarded to the nine Queens' intake centers by the Office of family and Adult Services payment unit for followup on the continued need for assistance. Pay- ment for the home attendant ceases if the case is not reauthor- ized by the expiration date. It is the responsibility of the clients to report to the intake center all changes in their financial circumstances and addresses. They are also to report if home attendants do not work the full number of scheduled hours. The intake center, in turn, forwards the data to the payment unit. DELAYS IN PAYMENT We reviewed 12 home attendant cases identified by your office as having problems with delayed reimbursement; that is, payments were not made to home attenda'ss on the regular 2-week basis. Delays generally ranged between 1 a-. 2 months, although we identified one 10-month delay attributed to a lost check. All the cases had incurred multiple delays and all had at least two different causes for their delays. Some delays were caused by the city and some by the clients' failure to report changes in their status or the status of the home attendants. New York City officials said they were aware of the delays and had pro- posed some prc;eduzai changes to correct the problems. Causes of delays City-caused delays for all 12 cass were attributable to seven basic reasons. The reasons are shown below with the number of cases affected by each in parenthesis. -- Late reauthorization of client eligibility (9). -- Delay in placing home attendant or client on payment rolls (8). -- Extra time for payment processing caused by the Queens pilot project (4). --Time-consuming processing to approve client's initial eligibility (3). 4 B-164031(3) -- Errors in data used for computer processing (3). -- Lost checks (3). -- Delayed decisions on client requests for special home attendant services (2). The most frequent cause of delay by the city involved slow reauthorization of beneficiary eligibility. In 9 of the 12 cases, clients and their attendants were temporarily dropped from the program because followup on reauthorization by the various Queens intake centers was not timely. Although a computer listing of cases due to expire in 60 days was prepared to alert the social workers, we were told that was 'not used because the Queens cases were not broken it down by the nine intake centers. We were also told that social workers did not Maintain 'tickler' files of casei by expira- tion date to alert them to follow up. In addition to delays caused by the city, Jome delays were caused by the clients' failure to promptly changes in their status or the status of the homereport This was a reason for delay in nine cases. Usuallyattendant. the change of status involved home attendants that quit, although times it involved an unreported change of address. some- Action by the city to correct problems City officiatls said they were aware of problems with home attendant program. Some told us that the problems the were caused by the fragmented program administration and staffing shortages. At the same time we were reviewing the management task force was also looking at theprogram, a city program. task force was established to identify program problems The recommend corrective actions. As we informed you in and March briefing, the task force identified a number of our istrative problems which contributed to late payment admin- attendants. The task force briefed the Commassioner of home New York City Department cf Social Services in March of the 1977 and suggested that (1) program administration be centralized (2) the existing organizational structure be streamlined or some administrative changes made, such as: and 5 B-164031(3) -- Establishing a 'tickler" system geared to utilize a computer listing which will be generated 75 days prior to the service expiration date .o assure that reauthorization procedures are initiated on time. -- Issuing pre-printed application forms and address labels to be sent to clients due fot reauthorization to get the client involved in the reauthorization' process earlier. City officials told us the second suggestion was accepted. The department agreed to new program procedures early in September 1977 and began implementing a new similar to the Queens pilot project, throughout the system, city. One official said the system should be in full operation by December 1977. In addition, they said oth-r. administrative changes were planned or had been made, such as centralizing the payment function for home attendant services and printinr, computer runs in a more useful format. At your request, we did not take the additional time obtain written comments. The matters covered to in the however, were discussed with an official in the HEW report, regional office who said that, upon receipt of our report, HEW will request the Commissioner of the New York State Department of sociaal Services to review the city's reimbursement practices. As arranged with your office, unless you publicly it;: contents earlier, we plan no further distribution announce report until 14 days from the date of the report. At of this time, we will send copies to interested parties and that make copies available to others upon request. Sincerely yours, / dreg Jy Ahart Director
Delays in Reimbursement for Home Health Services in New York City
Published by the Government Accountability Office on 1977-10-17.
Below is a raw (and likely hideous) rendition of the original report. (PDF)