Department of Health
Private Duty Nursing Services for Medicaid Recipients Private duty nursing services are included in New York State's Medicaid program. Federal regulations require that such services be furnished under the direction of the Medicaid recipient's physician by either a registered nurse (RN) or a licensed practical nurse (LPN), both of whom must possess a State license. Reimbursement for private duty nursing services rendered by RNs or LPNs is based on hourly fees. We analyzed Medicaid payments made during our audit period, and determined that the Medicaid Management Information System (MMIS) lacks sufficient controls for detecting providers that bill more than 24 hours in a day on behalf of the same Medicaid recipient. We also determined that MMIS lacks controls for detecting and preventing duplicate payments to private duty nursing providers. Because of these weaknesses, we determined that Medicaid may have overpaid providers of private duty nursing services more than $5.9 million for the period of January 1, 1996 through December 31, 1999. We recommend that these overpayments be investigated and recovered where appropriate, and that the Department of Health implement appropriate controls to prevent future overpayments.
For a complete copy of Report 99-S-16 click here.
For a copy of the 90-day response click here.
For a copy of the associated follow-up report click here.