New York Comptroller Audit Exposes $14.5 Billion in Unverified Medicaid Home Care Payments

An audit released by New York State Comptroller Thomas P. DiNapoli has revealed critical flaws in the state’s Medicaid program. Between January 2021 and March 2023, the program paid over $14.5 billion for home care services without sufficient electronic visit verification (EVV) documentation. This systemic issue leaves Medicaid vulnerable to fraud, overpayments, and insufficient care delivery.

Key Audit Findings

1. Lack of Verification Compliance
   Under federal mandates established by the 21st Century Cures Act, EVV systems are required for Medicaid-funded personal care (PC) and home health care (HHC) services. However, the audit found compliance rates of just 56% for PC and an abysmal 11% for HHC services. Despite these low rates, providers continued to receive payments without proof that the services were rendered.
2. Improper and Overpayments
   The audit identified over $21 million in improper claims, including:
   • $11.6 million paid for services too short to meet billing criteria.
   • $9.7 million paid for care provided while recipients were hospitalized, which Medicaid does not cover.
3. Systemic Oversight Failures
   Many providers with high billing rates were not informed of their obligation to conduct pre-claim reviews, further undermining compliance efforts. Moreover, the state’s lax enforcement allowed non-compliant providers to bypass regulations without penalties.
4. Statewide Implications
   These oversight failures are significant because Medicaid is a vital safety net, particularly for New York’s aging population and those with disabilities. The state spends billions annually on home care, but this audit raises questions about the efficiency and reliability of these critical services.

Comptroller Recommendations

DiNapoli’s office recommended immediate action to address these gaps, including:

• Enforcing EVV Compliance: Ensuring all providers adhere to federal requirements.
• Recovering Improper Payments: Investigating and reclaiming overpayments, particularly those tied to short or ineligible services.
• Strengthening Provider Oversight: Implementing stricter monitoring and training programs for high-billing providers.
• Enhancing Accountability Mechanisms: Introducing penalties for non-compliance and leveraging technology to bolster the verification process.

Implications for New York Medicaid

This report has far-reaching implications for New York’s Medicaid program, which serves over 7 million residents. Failure to resolve these systemic issues risks financial waste and could undermine trust in the program’s ability to deliver high-quality care. Critics argue that the state must act swiftly to close these gaps, especially as demand for home care services continues to rise due to the aging population.

Comparisons and Broader Context

Other states implementing EVV systems have faced similar challenges. However, New York’s scale of non-compliance is particularly alarming, given its position as one of the largest Medicaid programs in the U.S. DiNapoli’s audit echoes findings from previous reports highlighting inefficiencies and fraud risks in Medicaid’s administration.

Conclusion

As Medicaid spending balloons under the weight of increasing demand, oversight and accountability are more critical than ever. Comptroller DiNapoli’s audit underscores the urgent need for systemic reform to protect taxpayer dollars and ensure the integrity of home care services for vulnerable populations.For more detailed information, you can view the Comptroller’s press release and related documentation on the Office of the New York State Comptroller’s website