Supplemental Security Income:

Timely Data Could Prevent Millions in Overpayments to Nursing Home Residents

HEHS-97-62: Published: Jun 3, 1997. Publicly Released: Jun 3, 1997.

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Pursuant to a congressional request, GAO reviewed overpayments to Supplemental Security Income (SSI) recipients in nursing homes and other medical treatment institutions, focusing on: (1) the extent of such overpayments; (2) the success or failure of the Social Security Administration's (SSA) actions in preventing and detecting these overpayments; and (3) the methods by which SSA can better prevent such overpayments.

GAO noted that: (1) SSA estimates that overpayments to individuals in nursing homes may exceed $100 million annually; however, the exact extent is unknown; (2) despite SSA procedures to prevent overpayments, and recent legislation designed to further help prevent these overpayments to SSI recipients in nursing homes, GAO determined, based on SSA data, that it had detected overpayments totaling $24 million to about 31,000 recipients in fiscal year 1995; (3) in two states GAO visited, New York and Texas, GAO determined that SSA may not have been aware of an additional 1,699 SSI recipients recently admitted to nursing homes during a 1-month period and potentially overpaid these individuals $515,714 in benefits during the subsequent month alone; (4) SSA efforts to prevent these overpayments or detect them in a timely manner have had little success; (5) in many cases, recipients or their representative payees did not report the change in living arrangements in a timely manner; (6) in addition, because of other work priorities, SSA field representatives have not routinely contacted the over 23,000 U.S. nursing homes to solicit their cooperation in notifying SSA of admissions of SSI recipients, as SSA policies require; (7) furthermore, GAO's analysis of SSA data shows that overpayments to SSI recipients residing in nursing homes have increased by nearly 13 percent since the October 1995 effective date of the legislation that was designed to reduce overpayments; (8) SSA could more quickly detect overpayments by electronically obtaining nursing home admissions data directly from states to help identify recent changes in recipients' living arrangements; (9) SSA could then use an automated interface to automatically adjust the benefits of SSI recipients admitted to nursing homes who are ineligible for continuation of benefits due to temporary institutionalization and prevent the occurrence of overpayments for the ensuing months; (10) in the states GAO visited, GAO found that the state Medicaid agencies can make these data available to SSA; (11) SSA could use an existing data exchange system with states to obtain the needed data electronically; (12) in the interim period, while some states prepare their automated systems to make the electronic exchange of data with SSA, states could provide SSA with tapes or paper listings of this information for SSA's use in detecting overpayments; and (13) to identify the program improvements such an automated interface could produce, GAO conducted a joint effort with SSA and Tennessee that identified over $31,000 in overpayments.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: HHS continues to believe that providing nursing home admissions data to SSA via the Medicaid Statistical Information System or the Resident Assessment Instrument System (RAIS), which became operational in June 1998, is more efficient than requiring individual states to report to SSA. RAIS contains nursing homes admission data that is available to HCFA electronically from states on a monthly basis. Furthermore, HCFA could make the RAIS data available from all states to SSA on a monthly basis. GAO believes that this could accomplish the objectives of the recommendation.

    Recommendation: To prevent overpayments to SSI recipients in nursing homes or detect them sooner, the Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration (HCFA) to require states, as part of Medicaid management information systems (MMIS) systems requirements, to include information on nursing home admissions as standard data elements in their MMIS and make these data elements available to SSA electronically, in accordance with the laws and standards governing computer matching, privacy, and security.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: In fall 1998, SSA began a new semiannual computer match with monthly nursing home admissions data from the Health Care Financing Administration's Resident Assessment Instrument System (RAIS). In August 1999, SSA increased the frequency of the match from semiannual to monthly.

    Recommendation: The Commissioner of Social Security should establish agreements with the states to routinely obtain state MMIS data on nursing home admissions electronically as soon as feasible.

    Agency Affected: Social Security Administration

  3. Status: Closed - Not Implemented

    Comments: In lieu of obtaining nursing home admissions data directly from states, in the fall of 1998 SSA will begin semiannual computer matching with data from RAIS.

    Recommendation: The Commissioner of Social Security should establish interim agreements with state Medicaid agencies, while states adapt their systems to make this information available to SSA electronically, to obtain computer tapes or paper listings of admissions to nursing homes and use this information to identify overpayment situations and begin recovery actions and payment reductions.

    Agency Affected: Social Security Administration

  4. Status: Closed - Implemented

    Comments: SSA's Office of Quality Assurance and Performance Assessment conducted a study of the Resident Assessment Instrument System (RAIS) data it uses to conduct the nursing home match and determined that the data are not reliable enough to implement a system for automatic benefit reduction.

    Recommendation: The Commissioner of Social Security should determine the reliability of state MMIS data for purposes of supporting automatic benefit reductions for those SSI recipients identified as residing in nursing homes for a full month who are not eligible for continuation of full benefits due to temporary institutionalization and, if the data are reliable, implement a system for automatic benefit reduction.

    Agency Affected: Social Security Administration

 

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