More Than One-Third of New Jersey's Federal Medicaid Reimbursement for Providing Community-Based Treatment Services Was Unallowable

Federal regulations define rehabilitative services as services recommended by a licensed practitioner for maximum reduction of physical or mental disability and restoration of a beneficiary to their best possible functional level. State regulations for PACT, which the State agency defines in its Medicaid State plan as a rehabilitative program, stipulate that the prior authorization of services shall cover all dates that services were provided to ensure proper reimbursement. Although State regulations stipulate that a prior authorization should cover all dates of service, they do not specify a timeframe for which authorized services are eligible for Medicaid reimbursement. Essentially, this results in indefinite authorizations for PACT services for which providers are not required to reevaluate beneficiaries’ eligibility. Since the purpose of the PACT program is to restore the beneficiaries to their best possible functional level, lack of reevaluations over long periods of time may place beneficiaries’ quality of care at risk. In addition, beneficiaries may be receiving unnecessary intensive services when less intensive services might be sufficient. According to PACT services providers,requests for new authorizations are not submitted because some of the beneficiaries would no longer qualify for PACT services under a new authorization. We also observed that, in some cases, providers relied on prior authorizations obtained by beneficiaries’ previous providers; therefore, they did not reevaluate the beneficiaries’ need for PACT services. State agency officials contended that beneficiaries are, in effect, continually assessed while they are enrolled in PACT. However, the only assessment that PACT team psychiatrists are required to conduct is an annual psychiatric assessment (NJAC 10:37J-2.6(d)). Further, as described in the report, annual psychiatric assessments were not always performed by a psychiatrist.

Of the 100 sampled State agency claims for Federal Medicaid reimbursement of payments for PACT services, 50 complied with Federal and State requirements, but the remaining 50 did not. The deficiencies occurred because the State agency did not inform PACT providers of all Federal and State requirements for providing PACT services, and its monitoring procedures were not adequate to identify all instances when providers did not claim PACT services in accordance with these requirements. In fact, the monitoring procedures did not include checking whether some requirements were met. As a result, PACT providers did not follow requirements for providing PACT services.