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An Audit Report on the Health and Human Services Commission's Administration of Home Health Services within the Texas Health Steps Program

September 2012

Report Number 13-005

Overall Conclusion

The Health and Human Services Commission (Commission) paid $612.4 million for home health services that clients received through the Texas Health Steps program in fiscal year 2011.

Issues Regarding Personal Care Services

Among the various types of home health services that clients can receive, personal care services present the highest risk of inefficient or inappropriate use of resources. The levels of personal care services that clients receive are determined using unverified information that clients' parents or guardians provide about barriers that prevent them from caring for the clients themselves. In addition, the attendants who deliver personal care services are not regulated by professional boards and are often members of a client's family. The Commission should significantly strengthen its oversight of personal care services in the following areas:

- Obtaining required documentation of prospective clients' medical need for personal care services. Case managers from the Department of State Health Services (Department) conduct assessments of prospective clients for personal care services, and they are required to obtain practitioners' statements indicating that prospective clients have a medical need for personal care services. However, 28 (23 percent) of 120 personal care services client case files that auditors tested had no practitioner statements indicating that the clients had a medical need for personal care services. In contrast, medical need documentation was not obtained for 4 (7 percent) of 60 selected claims for therapy services and private duty nursing services.

- Collecting and analyzing information about diagnoses and practitioners for clients who receive personal care services. This could enable the Commission to understand the growth of those services and the significant differences in the use of those services in different parts of the state.

- Monitoring attendants for clients who receive personal care services. When a client receives personal care services, an attendant assists the client with the activities of daily living, such as bathing and dressing. However, the Department does not verify that the attendant delivered those services.

Issues Regarding All Texas Health Steps Program Home Health Services

For all types of home health services, the Commission should strengthen the oversight of its contracted claims administrator to ensure that it pays only valid claims. Auditors identified payment errors in 38 (23 percent) of 165 judgmentally selected home health services claims that the Commission's contracted claims administrator (the Texas Medicaid & Healthcare Partnership, or TMHP) paid in fiscal year 2011. Those errors resulted in overpayments totaling $15,141 (19 percent) of the $81,206 in claims tested. The Commission should ensure that TMHP corrects errors in its processes that resulted in TMHP making multiple payments for the same service and paying for more services than were authorized.

Auditors communicated other, less significant issues to the Commission and the Department in writing. Those issues involved inconsistent use of therapy payment rates and authorization periods, supervisory reviews of personal care services case files, data errors in the personal care services case management system, contract monitoring, and minor billing errors.

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