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)

                               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
Congressional Relevance: Rep. Benjamin S. Rosenthal.
Authority: Social Security Act, as amended, title XIX   (42 U.S.C.
         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,
              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
        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.
              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
                                                      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.
         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


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
     --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!

l/Except for the Borough of Manhattan, where the Office of
   Family and Adult Services handles case management.


       -- 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
 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
      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
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
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.


     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.
     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).


      -- 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.
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
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
caused by the fragmented program administration and staffing
     At the same time we were reviewing the
management task force was also looking at theprogram, a city
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


     -- 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,
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
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,
office who said that, upon receipt of our report, HEW
request the Commissioner of the New York State Department
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
copies available to others upon request.

                             Sincerely yours,

                           / dreg       Jy Ahart