Improper Capitation Payments
Learn how the AI-generated research projects were createdOverall Conclusion
The Department has processes to identify and recoup improper capitation payments, but controls are not sufficiently robust to ensure all improper payments are identified and recouped. The audit identified over $118.5 million in improper capitation payments not recouped for SFYs 2018-2020, with substantial amounts involving duplicates, incarcerated, and deceased individuals. The Department has implemented improvements, including automation, dashboards, and robotic process automation, since 2019-2021, but further actions are required to fully recoup payments and prevent future errors.
Source Document
Audit Scope
SFYs 2018-2020 (July 1, 2017 through June 30, 2020). Focus on capitation payments to managed care organizations for Medicaid recipients, specifically duplicate payments due to multiple IDs, payments during incarceration, and payments after death; cross-matching data from Medicaid, ODRC, and ODH; analysis used Medicaid database and MITS; results include primary and secondary matches and recommendations for recoupment.
Key Findings Summary
Identified over $118.5 million in improper capitation payments that had not been recouped by the Department in SFYs 2018-2020.
Duplicate capitation payments: 61,852 capitation payments totaling $29,175,678 were made on behalf of recipients with the same SSN; approximately $14.5 million not recouped.
Additional potential duplicate matches: 15,597 matches totaling about $134,906,167; potential savings up to $67.5 million.
View the Findings tab to see all 7 findings
AI-Assisted
AI Scope Summary
This audit expands on the objectives of identifying duplicate capitation payments, payments during incarceration, and payments after death, and assessing recoupment effectiveness. For future Medicaid audits, a deeper review of recoupment timing, the impact of PHE-related payment adjustments, and the effectiveness of automated alerts and dashboards could be pursued to strengthen controls and ensure full recoupment of improper payments.
AI-Generated Insight
The audit underscores the critical role of data quality in the Ohio Benefits eligibility system and highlights how automation, dashboards, and robotic process automation were introduced to reduce improper capitation payments. Ongoing monitoring and data governance are essential to sustain improvements in recoupment and rate-setting accuracy.
Audit Objectives
Identify duplicate capitation payments for recipients with multiple Medicaid recipient IDs that were not recouped.
Identify capitation payments for incarcerated adults that were not recouped.
Identify capitation payments for deceased individuals that were not recouped.
Audit Findings (7)
Identified over $118.5 million in improper capitation payments that had not been recouped by the Department in SFYs 2018-2020.
Duplicate capitation payments: 61,852 capitation payments totaling $29,175,678 were made on behalf of recipients with the same SSN; approximately $14.5 million not recouped.
Additional potential duplicate matches: 15,597 matches totaling about $134,906,167; potential savings up to $67.5 million.
Incarcerated payments: 29,412 recipients and 160,850 capitation payments totaling $100,663,282 not recouped; 1,281 potential matches with over $4 million in additional payments.
Deceased payments: 3,560 capitation payments totaling $3,383,680 not recouped; 904 potential matches with about $12.6 million in additional payments.
Data validity issues: missing first/last names, DOBs, and over 80,000 recipients with invalid SSNs (000-00-0000 or 999-99-9999).
Fee-for-service payments analysis identified over $8 million in potential improper payments during managed care enrollment; requires further analysis.
Recommendations (5)
Recover the approximately $14.5 million in duplicate capitation payments, $100,663,282 in capitation payments for incarcerated individuals and $3,383,680 in capitation payments for deceased individuals from the managed care organizations (MCOs) and refund the federal share.
Review potential improper capitation payments for each objective and identify and recoup all improper capitation payments.
Evaluate current processes for identifying duplicate recipient IDs, incarcerated individuals and deceased individuals and updating recipient data files in a timely manner.
Assess the steps taken to recoup all appropriate capitation payments when a change occurs that impacts eligibility, such as incarceration or when a duplicate payment is identified.
Correct or enhance system controls to prevent future erroneous capitation payments and improve accuracy of data on participation in the Medicaid program.