Home Health & Hospice Week

Conflicts of interest continue to plague Medicaid home care programs, possibly leading to ineligible patients receiving care and improper payments, the Government Accountability Office says in a new report.

Home- and community-based service pro-viders "may have a financial interest in the outcome of needs assessments, which could lead to overstating needs and overprovision of services," the GAO says in its report summary.

"CMS has addressed risks associated with HCBS provider conflicts, such as by requiring states to establish standards for conducting certain needs assessments," the GAO says. "But these requirements do not cover all types of HCBS programs."

Plus: "Requirements for states to establish standards to address HCBS providers' potential for conflict of interest in conducting needs assessments that are used for service planning do not apply across all programs," the GAO says.

The opposite conflict applies to managed care plans, the GAO notes. "Managed care plans could have an incentive to enroll beneficiaries with few needs, as plans typically receive a fixed payment per enrollee," the report says.

For example: "A plan in one state admitted in a settlement with the federal government to enrolling 1,740 individuals ... whose needs did not qualify them," the GAO offers.

In 2013, CMS issued guidance that managed care plans may not be involved in eligibility assessments for HCBS, the GAO noted. "But CMS has not consistently required states to prevent this involvement," the report notes.

Recommendation: "GAO recommends that CMS ensure that all Medicaid HCBS programs have requirements for states to address both service providers' and managed care plans' potential for conflicts of interest in conducting assessments," the report says. CMS agreed with the recommendation.

See the report at www.gao.gov/products/GAO-18-103.