Office of Inspector General
25 indexed reports
Medicaid Agencies Made Millions in Unallowable Capitation Payments to Managed Care Organizations on Behalf of Deceased Enrollees
We estimate that Medicaid agencies made $207,501,380 ($138,645,710 Federal share) in unallowable capitation payments to MCOs for deceased enrollees during the audit period (July 1, 2021 – June 30, 202...
Illinois Medicaid Managed Care Capitation Payments for Incarcerated Enrollees
The audit determined that Illinois made unallowable managed care capitation payments for incarcerated enrollees during the audit period, totaling at least $9.5 million with $8.3 million Federal share,...
Wisconsin’s Fee-for-Service Medicaid Payments for Applied Behavior Analysis
The Wisconsin Department of Health Services’ ForwardHealth program did not provide adequate oversight of FFS Medicaid ABA payments, resulting in improper and potentially improper payments for autism-r...
Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
The OIG concluded that Pennsylvania made unallowable capitation payments totaling at least $8,784,549 ($4,596,390 Federal share) for enrollees with multiple Medicaid ID numbers during the audit period...
Analysis of Selected Nursing Facilities’ Use of Medicaid Reimbursement for Direct Care Compensation
The data brief concludes that there is no clear, positive correlation between higher direct care compensation and higher nursing hours per resident day (HPRD). Increases in direct care compensation ar...
Maryland Did Not Comply With Federal Waiver and State Requirements at 20 Adult Day Care Facilities Audited
The Maryland Department of Health did not fully comply with Federal waiver and State requirements in overseeing adult day care facilities; 253 noncompliance instances were identified across health and...
Audit Of Ohio Adult Day Health Care Services
The Ohio Department of Medicaid did not fully comply with Federal waiver and State requirements in overseeing providers serving adults in the ADS program; inspections were insufficient to ensure a con...
School-Based Fee-for-Service Medicaid Reimbursements
The audit identifies widespread weaknesses in Kansas’s school-based Medicaid FFS program, including policy misalignments with federal guidance, documentation gaps, and data integrity issues that contr...
Texas Did Not Fully Comply With Federal Waiver And State Health, Safety, And Administrative Requirements At All 20 Adult Day Activity And Health Service Facilities Audited
The State agency did not fully comply with Federal waiver and State requirements in overseeing DAHS facilities serving people with special health care needs, and its inspections were not sufficient to...
North Carolina’s Medicaid Control Environment, Risk Management Practices, and Governing Processes Were Assessed as Moderate Risk
Overall, the audit determined that North Carolina's Medicaid control environment, risk management practices, and governing processes operate at a moderate risk level, with three risk areas rated high ...
Colorado Made Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
The audit found that Colorado made unallowable capitation payments to Medicaid managed care organizations for deceased enrollees, resulting in significant financial losses and reporting inaccuracies. ...
Twelve Selected States Did Not Accurately Calculate the Federal Share of Medicaid Collections Subject to the Increased COVID-19 Federal Medical Assistance Percentages
Twelve of the thirteen selected States did not accurately calculate the Federal share of Medicaid collections subject to the increased COVID-19 FMAP, resulting in net underreporting of $61.8 million. ...
California Payments for Enrollees With Concurrent Medicaid Enrollment in Another State
We estimated that the State agency incurred costs of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments made on behalf of enrollees who were residing and con...
North Carolina Did Not Report and Return All Medicaid Overpayments for the State's Medicaid Fraud Control Unit Cases
The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for the period under review (October 1, 2019 through September 30, 2021).
California Improperly Claimed $52.7 Million in Federal Medicaid Reimbursement for Capitation Payments Made on Behalf of Noncitizens With Unsatisfactory Immigration Status
California improperly claimed Federal Medicaid reimbursement for capitation payments to noncitizens with UIS by applying an outdated proxy percentage that did not reflect the true costs of nonemergenc...
Colorado's Program Integrity Section Reporting of Medicaid Overpayments
Colorado did not report and refund the correct Federal share of Medicaid overpayments identified by its Program Integrity Section during Oct 1, 2014 through Dec 31, 2020; 80 of 403 cases contained unr...
CMS Did Not Ensure That Selected States Complied With Medicaid Managed Care Mental Health and Substance Use Disorder Parity Requirements
CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contrac...
Medicaid Capitation Paid for Members Residing in Other States
Rhode Island Medicaid paid approximately $38.4 million in capitation payments to MCOs for members who were not residing in Rhode Island, indicating noncompliance with state and federal residency requi...
Colorado Could Better Ensure That Nursing Homes Comply With Federal Requirements For Life Safety, Emergency Preparedness, And Infection Control
Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were ob...
Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
The report concludes that improper Medicaid capitation payments to MCOs on behalf of deceased enrollees remain a persistent issue across states, with prior unallowable payments totaling about $249 mil...
States Face Ongoing Challenges in Meeting Third-Party Liability Requirements for Ensuring That Medicaid Functions as the Payer of Last Resort
OIG concludes that States continue to face persistent and wide-ranging challenges in meeting third-party liability requirements for Medicaid, even after the Deficit Reduction Act provisions and CMS gu...
New York Did Not Ensure That A Managed Care Organization Complied With Requirements For Denying Prior Authorization Requests
The audit concluded that the New York State Department of Health’s oversight was ineffective in ensuring that CPHL complied with requirements for denying prior authorization requests, resulting in del...
The Centers for Medicare & Medicaid Services’ Review Contractors Generally Conducted Medicaid Fee-for-Service Claim Reviews for Selected States Under the Payment Error Rate Measurement Program in Accordance with Federal and State Requirements
CMS’s review contractors adequately conducted Medicaid FFS claim reviews for three States (Arkansas, Connecticut, and New Mexico) under the PERM program in accordance with Federal and State requiremen...
Nearly All States Made Capitation Payments for Beneficiaries Who Were Concurrently Enrolled in a Medicaid Managed Care Program in Two States
CMS did not concur with the recommendations. The OIG maintains that the recommendations are valid and will continue to work with States to identify opportunities to reduce the number and amount of con...