California Did Not Report and Return All Medicaid Overpayments for the State’s Medicaid Fraud Control Unit Cases
Learn how the AI-generated research projects were createdOverall Conclusion
The State agency did not report and return the Federal share of all Medicaid Fraud Control Unit-determined Medicaid overpayments identified for FY 2023.
Source Document
Audit Scope
Audit period October 1, 2022, through September 30, 2023 (FY 2023); review of MFCU-determined Medicaid overpayments and reporting on Form CMS-64.
Key Findings Summary
The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for FY 2023.
Specifically, 14 cases involving paid claim overpayments totaling $113,269,575 ($47,769,205 Federal share) were not reported and returned on Form CMS-64.
A court-ordered award totaling $27,515 ($11,006 Federal share) was not reported and returned on Form CMS-64.
View the Findings tab to see all 6 findings
AI-Assisted
AI Scope Summary
This audit aimed to determine whether California’s Department of Health Care Services reported and returned the correct Federal share of MFCU-determined Medicaid overpayments identified during FY 2023, and to assess the timeliness and accuracy of reporting on Form CMS-64, with conclusions guiding improvements for future Medicaid overpayment reporting audits.
AI-Generated Insight
California’s underreporting and delays in reporting the federal share of MFCU recoveries reveal weaknesses in internal controls and coordination with MFCU. Strengthening procedures and adherence to federal reporting timelines are essential to ensure timely, accurate federal reimbursements.
Audit Objectives
Our objective was to determine whether the State agency reported and returned the correct Federal share of MFCU-determined Medicaid overpayments identified during the period October 1, 2022, through September 30, 2023 (Federal fiscal year 2023).
Audit Findings (6)
The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for FY 2023.
Specifically, 14 cases involving paid claim overpayments totaling $113,269,575 ($47,769,205 Federal share) were not reported and returned on Form CMS-64.
A court-ordered award totaling $27,515 ($11,006 Federal share) was not reported and returned on Form CMS-64.
The State agency did not report and return $74,879,534 ($32,102,769 Federal share) for 14 cases within the required timeframe.
The State agency correctly reported and returned $43,024,883 ($19,458,161 Federal share) on Form CMS-64 for 10 cases.
The unreported and untimely reporting occurred because the State agency lacked policies and procedures to ensure that all MFCU case files were sent to the State agency, relied on MFCU for information, and followed inconsistent calculations and reporting practices regarding federal share; in cases under state FCA, attorney fees and relator’s shares were deducted before FMAP application.
Recommendations (4)
Report and return the Federal share of Medicaid overpayments for the 14 unreported cases totaling $113,269,575 ($47,769,205 Federal share).
Report and return the Federal share of the collected court-ordered award for one case, totaling $27,515 ($11,006 Federal share).
Work with the Medicaid Fraud Control Unit to revise the MOU notification timeline to facilitate timely notification of final judgments to meet Federal requirements.
Develop written policies and procedures to facilitate timely and complete reporting of all identified overpayments, regardless of payment status, and to ensure accurate calculation of the Federal and State shares of overpayments in accordance with Federal requirements.