Medicaid dollars go undocumented; Findings issued against healthcare provider
Insufficient records and care given that was never ordered by a doctor led to more than $195,000 in findings issued in the Medicaid provider audit of Carol S. Sito, LPN (Ashtabula County), released by Auditor of State Dave Yost.
“She was warned that her documentation was bad, and she ignored it,” Auditor Yost said.
“Improper payment for home care is one of the most common areas of waste and fraud in one of the largest government programs there is, and good records are about the best tool we have to fight against that.”
The 2010 financial report for U.S. Health and Human Services estimated that 9.4 percent of all payments to Medicaid providers was improper, with the nationwide federal share alone estimated at $22.5 billion.
Ohio spends more than $18 billion annually on Medicaid, including both state and federal share.
The audit reviewed claims for services Carol S. Sito, LPN rendered to Medicaid patients and payments received during the period of July 1, 2007 to April 30, 2011.
During that time, Sito was reimbursed $377,657.73. Due to insufficient or missing documentation, a total of $195,153.21 in findings was issued, along with $19,675.72 in interest. Additional interest will accrue at the rate of $42.77 per day after August 20, 2012 until the findings are repaid.
During the audit period, Sito failed to prepare clinical records and timesheets for services according to Medicaid rules. Instead, she made photocopies of prior clinical notes, and many timesheets did not contain original signatures. Prior to the audit period in 2007, Sito was warned by ODJFS that this practice was unacceptable. As a result, the Auditor of State’s office disallowed $121,238.39 in reimbursements.
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Auditors also identified one plan of care that was not signed by a physician, and therefore is invalid. Reimbursements for the 61 services covered in this plan of care were disallowed, and a finding in the amount of $18,623.01 was issued.
There also were 18 services billed after a plan of care expired. The reimbursements were disallowed, and a finding of $5,268.21 was issued.
According to Ohio Medicaid rules, services not specifically stated in a plan of care or an all-services plan are not reimbursable. Auditors reviewed Sito’s records and identified 1,488 hours of service (5,952 units) that were overbilled to Ohio Medicaid, and a finding of $50,023.60 was issued.