Timely Notification of Inpatient Hospital Stays Could Help Reduce Improper Medicaid Payments
Learn how the AI-generated research projects were createdOverall Conclusion
OHA lacks timely notification of inpatient hospital stays, which results in some claims being paid for services not provided because the Medicaid client was in the hospital; there is significant improper payments and high-risk claims related to in-home services, NEMT, and private duty nursing during inpatient stays; improvement through notifications and controls is needed.
Source Document
Audit Scope
Paid Medicaid claims from January 2017 to February 2020 for recipients who experienced extended in-patient hospital stays. The scope did not include Medicaid claims during the COVID-19 pandemic.
Key Findings Summary
Testing identified $52,344 in improper payments to providers not associated with the hospital who likely did not provide services, and approximately $1.6 million in additional payments identified as high risk of being improper.
In-home services are not allowable during inpatient hospital stays; testing found $49,875 in improper payments across 42 claims, and we estimate approximately $1.3 million in other in-home service claims that are at high risk of being improper.
Non-emergency medical transportation (NEMT) had $1,644 in improper payments across 73 claims, with about $211,507 in other NEMT claims at a high risk of being improper.
View the Findings tab to see all 5 findings
AI-Assisted
AI Scope Summary
This audit builds on the objective of ensuring Medicaid claims during extended inpatient stays comply with program policies and suggests future audits to evaluate the effectiveness of automated hospital-admission notifications and cross-system data sharing (EVV, Collective Platform) in reducing improper payments across in-home services, NEMT, and private duty nursing.
AI-Generated Insight
The audit reveals a gap in real-time inpatient stay notification within Oregon's Medicaid processes, enabling improper payments across in-home services, NEMT, and PDN during extended hospital stays. It highlights opportunities for cost-effective automation, EVV implementation, and cross-agency coordination (OHA and ODHS) to prevent payments for unallowable services, with potential savings by tightening MMIS edits and improving hospital-admission notifications.
Audit Objectives
Determine whether the Oregon Health Authority processes Medicaid claims in accordance with program policies for services billed while a client is in an extended hospital stay.
Audit Findings (5)
Testing identified $52,344 in improper payments to providers not associated with the hospital who likely did not provide services, and approximately $1.6 million in additional payments identified as high risk of being improper.
In-home services are not allowable during inpatient hospital stays; testing found $49,875 in improper payments across 42 claims, and we estimate approximately $1.3 million in other in-home service claims that are at high risk of being improper.
Non-emergency medical transportation (NEMT) had $1,644 in improper payments across 73 claims, with about $211,507 in other NEMT claims at a high risk of being improper.
Private duty nursing: $825 in improper payments across three claims, with about $5,982 in other private duty nursing claims at a high risk of being improper.
OHA lacks timely notification of inpatient hospital stays, leading to payments for services not provided while a Medicaid client is in the hospital.
Recommendations (2)
Reimburse the federal government for the federal portion of the identified improper payment amount.
Develop and implement cost-effective controls that would prevent or detect improper payments for unallowable services while a Medicaid client is inpatient, including timely notification of hospital admissions integrated into claims processing.