Pursuant to state regulations, HHAs must be certified prior to performing PCS and PCS providers, including HTH, must ensure that HHAs who perform PCS on their behalf possess the required certification before allowing such personnel to perform these services.

OSC found that for 1 of the 118 sample claims, totaling $44.40 paid to HTH, HTH failed to ensure that the HHA was properly certified, thus allowing an uncertified individual to perform services. In this instance, the HHA provided PCS on December 30, 2015, however, the HHA’s temporary HHA permit had expired on June 30, 2015. By failing to verify that this HHA was certified and thereby allowing the HHA to perform services six months after the individual’s temporary work permit had expired, HTH violated N.J.A.C. 10:60-1.2 (definition of “[h]omemaker-home health aide”) and N.J.A.C. 13:45B-14.4 (a) and (c). See Appendix A for claim detail.

Pursuant to N.J.A.C. 10:60-1.2, “‘Homemaker-home health aide’ means a person who: Successfully completes a training program in personal care assistant services and is certified by the New Jersey State Department of Law and Public Safety, Board of Nursing, as a homemaker-home health aide.” That definition further provides that “[a] copy of the certificate issued by the New Jersey Department of Law and Public Safety, Board of Nursing or other documentation acceptable to the Division [must be] retained in the agency's personnel file.”

Pursuant to N.J.A.C. 13:45B-14.4(a), “When licensure to perform a health care service or function is required by law, an agency shall refer or place only those health care practitioners who are currently licensed or certified and in good standing with their respective New Jersey licensing or registration boards.” N.J.A.C. 13:45B-14.4(c) further provides that “[t]he agency shall, through its health care practitioner supervisor or other designated individual, verify the license status of each individual to be placed or referred prior to the referral or placement. Licensure shall be verified by obtaining a document, which verifies licensure from the Board or Committee that registers or licenses the individual and, within 45 days of obtaining the verification, by personally inspecting the current biennial registration or license or a copy of the current biennial registration or license.”

Medicaid PCS providers must perform an in-home evaluation of the HHA and the beneficiary’s POC not less than once during each 60-day period. Timely completion of the in-home evaluation is required to evaluate the HHA’s performance and to determine whether the services called for in the POC meet the needs of the beneficiary and, if not, to make any necessary changes thereto. Since a beneficiary’s needs can change, the POC must be updated to account for such changes in a beneficiary’s health and wellbeing.

OSC reviewed the documentation to determine whether HTH completed the in-home evaluation of the HHA and the POC at least once every 60 days. OSC found that for 14 of the 118 sample claims, totaling $689.06 paid to HTH, HTH did not perform the in-home evaluation of the HHA and the POC once every 60 days. For example, for services rendered by HTH to a beneficiary on February 28, 2018, HTH last completed the in-home evaluation of the beneficiary’s HHA and POC on October 27, 2017, 124 days before the date of service. HTH did not complete any subsequent in-home evaluations for this beneficiary. See Exhibit I. In another instance, HTH billed for PCS services rendered on August 30, 2014, but the two in-home evaluation visits for that beneficiary took place on May 23, 2014 and November 13, 2014, resulting in a 174-day span between the two in-home evaluations. See Exhibit II. For these claims, HTH violated N.J.A.C. 10:49-9.8(a), N.J.A.C. 10:60-3.5(a)(2), and N.J.A.C. 13:45B-14.9(g) by not performing in-home evaluations of the POC within the required timeframe. See Appendix A for claim detail.

Pursuant to N.J.A.C. 10:49-9.8(a), “all providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:60-3.5(a)(2), “Direct supervision of the personal care assistant shall be provided by a registered nurse at a minimum of one visit every 60 days, initiated within 48 hours of the start of service, at the beneficiary's place of residence during the personal care assistant's assigned time. The purpose of the supervision is to evaluate the personal care assistant's performance, to determine that the plan of care has been properly implemented, and to document that hands-on personal care is being provided. At this time, appropriate revisions to the plan of care shall be made as needed . . . .”

Pursuant to N.J.A.C. 13:45B-14.9(g), “The health care practitioner supervisor shall make an on-site, in home evaluation of the plan of care not less than once during each 60 day period during which the agency has placed or referred a health care practitioner in the home care setting.”

Medicaid PCS providers must maintain records that are true, accurate and complete. Further, the records must document fully the extent of services provided. OSC reviewed HTH’s timesheets to determine whether HTH maintained proper documentation for its Medicaid-billed services. OSC found that for 3 of the 118 sample claims, totaling $166.62 paid to HTH, HTH billed for services that were not supported by documentation. Specifically, OSC found that HTH billed for PCS for 2 of the 3 claims, totaling $69.90, for which HTH did not provide a timesheet to support the PCS. Further, OSC found for 1 of the 3 claims, totaling $96.72, the timesheet was incomplete as the services performed were not documented. For these claims, HTH violated N.J.A.C. 10:49-9.8(a), and N.J.A.C. 10:49-9.8(b)(1) by failing to maintain appropriate records. See Appendix A for claim detail.

Pursuant to N.J.A.C. 10:49-9.8(a), “all providers shall certify that the information furnished on the claim is true, accurate, and complete.” Moreover, pursuant to N.J.A.C. 10:49-9.8(b)(1), providers are required “to keep such records as are necessary to disclose fully the extent of services provided.”

Medicaid PCS providers must evaluate the beneficiaries’ needs and establish a written POC prior to initiating service. This requirement ensures that PCS providers identify the HHA tasks and hours of service needed before sending an HHA to provide services. It also ensures that the HHA knows the beneficiary’s needs before providing services to the beneficiary. OSC found that HTH billed for PCS for 1 of the 118 sample claims, totaling $29.60 paid to HTH, without first having completed a POC before rendering services. For this claim, HTH violated N.J.A.C. 10:49-9.8(a) and N.J.A.C. 13:45B-14.9(a) by not preparing the POC prior to rendering services. See Appendix A for claim detail.

Pursuant to N.J.A.C. 10:49-9.8(a), “all providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 13:45B-14.9(a), “Prior to referring or placing a health care practitioner in a home care setting, an agency shall assure that an appropriately licensed person evaluates the patient's needs and establishes, in writing, a plan of care. The health care practitioner preparing the plan of care shall sign it and indicate thereon his or her license designation.”

Apart from the review of the sampled claims, OSC also reviewed HTH’s home-based PCS claims billed under the HCPCS code T1019 to determine whether such claims overlapped with dates when beneficiaries were in a hospital. OSC found that HTH submitted 46 claims, totaling $2,155.42 paid to HTH, for services purportedly provided to beneficiaries in a home setting while these beneficiaries had inpatient status in a hospital. Pursuant to Medicaid regulations, a beneficiary cannot receive PCS, Private Duty Nursing, or In-Home-Nursing services, while Medicaid is paying a hospital for room and board services for the same beneficiary. Therefore, these 46 claims constitute overpayments that HTH must repay to the Medicaid program. For these claims, HTH violated N.J.A.C. 10:49-9.8(a) and N.J.A.C. 10:60-3.8(a) by improperly billing for PCS while a beneficiary has inpatient status in a hospital. See Appendix B for claim detail.

Pursuant to N.J.A.C. 10-49-9.8(a), “providers shall certify that the information furnished on the claim is true, accurate, and complete.”

Pursuant to N.J.A.C. 10:60-3.8(a)(1)-(3) and (8), “Medicaid/NJFamilyCare reimbursement shall not be made for personal care assistant services provided to Medicaid or NJ FamilyCare –Plan A beneficiaries in the following settings: A residential health care facility; A Class C boarding home; A hospital; . . . Adult Family Care, Assisted Living Program, and Assisted Living Residence.”

OSC determined that HTH improperly billed and received payment for 19 of the 118 sample claims, totaling $929.68 paid to HTH. See Appendix A for Summary. For purposes of ascertaining a recovery amount, OSC extrapolated the dollars in error for these 19 claims to the total population of 296,374 claims from which the sample claims was drawn, totaling $16,092,741.69 paid to HTH. By extrapolating the sample of deficient claims to this universe of claims/reimbursement amount, OSC calculated that HTH received an overpayment of $2,384,132.55 that it must repay to the Medicaid program.[1] Additionally, OSC determined that HTH improperly billed and received payment for 46 claims, totaling $2,155.42, for services provided to beneficiaries while these beneficiaries had inpatient status in a hospital setting. In total, OSC determined that HTH received an overpayment of $2,386,287.97 ($2,384,132.55 plus $2,155.42) that it must repay to the Medicaid program.