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Highlights

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.

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Recommendations

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Health and Human Services 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.
Closed - Not Implemented
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.
Social Security Administration 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.
Closed - Implemented
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.
Social Security Administration 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.
Closed - Not Implemented
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.
Social Security Administration 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.
Closed - Implemented
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.

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