New York’s Department of Health failed to adequately oversee Medicaid Health Homes, resulting in delayed reviews, weak compliance and nearly $20 million in questionable payments, according to a state audit released in January.
The Office of the State Comptroller found the department “did not adequately oversee Medicaid Health Homes to ensure appropriate care and payments” between January 2019 and June 2023.
Health Homes coordinate care for Medicaid recipients with chronic conditions. During the audit period, Medicaid paid $3 billion for Health Home services provided to more than 431,000 members.
The audit found oversight breakdowns in several key areas.
Delayed and inconsistent reviews
The Department of Health conducts periodic “redesignation reviews” to evaluate Health Homes’ compliance and performance. But auditors found many reviews were not completed on time.
In the second round of reviews, 11 of 25 Health Homes — 44% — were delayed by more than six months . In the third round, which began in 2023, 10 of 18 required reviews — 56% — were not completed on time as of October 2024 .
The comptroller’s office said delays allowed Health Homes “to operate for periods without this key monitoring process”.
Poor documentation and care planning
Auditors also found widespread compliance problems in patient records.
Across 18 Health Homes reviewed in one round, compliance rates fell below 90% on 46 of 66 patient chart questions . Fifteen of the 18 homes had less than 90% compliance on more than half of the measures.
Common problems included failing to update members’ plans of care, incomplete comprehensive assessments and missing enrollment documentation.
In a separate sample of 50 member files, auditors found 68% lacked documented risk factors in the plan of care and 66% were not screened for all required areas during the comprehensive assessment.
Questionable payments
The audit identified $19.7 million in Medicaid payments across 67,026 claims that lacked proper support in the state’s Medicaid Analytics Performance Portal, known as the MAPP system.
The unsupported payments included claims with no attested core service, claims marked voided in the system but still paid, and claims billed at higher rates than calculated.
In a sample of 50 claims reviewed with Health Homes, 35 were not justified, according to the audit.
Performance measures questioned
Auditors also found the department does not use baseline data — such as a member’s health status before enrollment — when calculating performance measures.
In an analysis of 29,168 members with continuous enrollment before and after joining a Health Home, 95% of performance measure calculations showed less than a 3% change after enrollment.
The report said without baseline data, it is difficult to determine whether Health Homes are improving outcomes or reducing costs.
Recommendations and response
The comptroller’s office issued seven recommendations, including conducting timely reviews, strengthening oversight of billing support, evaluating the use of baseline data and recovering improper payments.
In its response, the Department of Health generally agreed with the recommendations and said it has made improvements since 2023, including revising the redesignation process and adding safeguards in the billing system.
Under state law, the department must report within 180 days on steps taken to implement the audit’s recommendations.
FingerLakes1.com is the region’s leading all-digital news publication. The company was founded in 1998 and has been keeping residents informed for more than two decades. Have a lead? Send it to [email protected].