The Cost of Concurrent Enrollment
Learn how the AI-generated research projects were createdOverall Conclusion
The audit highlights significant financial waste due to unmanaged concurrent Medicaid enrollment across states, emphasizing the need for technological improvements, better inter-state communication, and proactive identification processes to safeguard public funds.
Source Document
Audit Scope
This audit covers the impact of concurrent Medicaid enrollment in Ohio during the period from January 1, 2019, through December 31, 2022, focusing on capitation payments made to enrollees who were concurrently enrolled in Ohio and at least one other state, with particular attention to the top 11 states with the highest number of shared enrollees.
Key Findings Summary
Over 124,000 recipients enrolled concurrently in Ohio and other states from 2019 to 2022, with Ohio spending over $1 billion on capitation payments for these individuals.
Estimated impact of over $209 million due to out-of-state residency among sampled enrollees.
40% of tested capitation payments could not be confirmed as Ohio residents, indicating potential overpayments.
View the Findings tab to see all 7 findings
AI-Assisted
AI Scope Summary
The audit aims to quantify the financial impact of concurrent Medicaid enrollment in Ohio, evaluate current detection and resolution procedures, and recommend improvements to prevent unnecessary expenditures.
AI-Generated Insight
This report underscores the systemic challenges in managing Medicaid residency verification and the substantial financial implications of concurrent enrollment. Implementing technological and procedural enhancements could significantly reduce waste and improve program integrity.
Audit Objectives
Determine the impact of concurrent Medicaid enrollment on Ohio’s program during the period of January 1, 2019 through December 31, 2022.
Assess the procedures used by Ohio Medicaid to detect and address concurrent enrollment.
Audit Findings (7)
Over 124,000 recipients enrolled concurrently in Ohio and other states from 2019 to 2022, with Ohio spending over $1 billion on capitation payments for these individuals.
Estimated impact of over $209 million due to out-of-state residency among sampled enrollees.
40% of tested capitation payments could not be confirmed as Ohio residents, indicating potential overpayments.
The Medicaid program lacks adequate procedures for preventing, timely identifying, and resolving concurrent enrollments.
Self-attested residency information leads to inaccuracies and potential for out-of-state enrollment.
Federal and state requirements for residency are not sufficiently enforced or verified.
The PARIS system and other alerts are underutilized and overwhelmed, leading to delays in resolving residency issues.
Recommendations (5)
Request CMS to provide data matches based on T-MSIS data to identify unresolved concurrent enrollments.
Conduct follow-up reviews of subsequent concurrent enrollment data to ensure timely resolution.
Enhance technology use in application and enrollment processes to identify existing enrollments in other states.
Expand application questions to proactively identify potential concurrent enrollment.
Improve the clearing and resolution of PARIS alerts through better communication and system enhancements.