Inspector General Criticizes Three States For Improper Medicaid Claims

Cheryl Clark, for HealthLeaders Media , September 16, 2009

The Office of Inspector General has issued lengthy audit reports for Pennsylvania, Connecticut, and Texas documenting the extent to which each state's agencies sent in claims for more reimbursement than they could justify.

In Pennsylvania, Medicaid officials have disallowed one in 10 sampled state claims for reimbursement of case management services targeting people with mental illness or mental retardation, about $11.8 million, because they lacked case record support.

About $6.5 million of the amount was spent from federal funds, which the OIG recommends the state should refund.

In Connecticut, Medicaid officials have questioned $19.8 million in claims for 80 contracted mental health and related social services. Connecticut's documentation did not contain enough information to determine whether the claims qualified for payment.

"The state agency's calculation of the CBMACs (Community Based Medicaid Administrative Claim) was based on the Medicaid-allocable costs incurred by the 80 contracted organizations ($161,480,735), which exceeded by $19 million the total amount that the DMHAS (the Department of Mental Health and Addiction Services) actually paid to these contracted organizations for both Medicaid and non-Medicaid services and activities," the OIG audit said.

And, in Texas, 22% of sampled medical claims for care provided to undocumented immigrants did not satisfy the state's definition of emergency care. In Texas, as in other states, coverage for medical care and prescription drugs for undocumented people is allowed only during medical emergencies. The amount in question involved 193 of 854 claims for care, totaling $262,000, which lacked documentation.

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