Wisconsin May Have Improperly Claimed $455 Million in Medicaid Reimbursement for Its School-Based Program
Learn how the AI-generated research projects were createdOverall Conclusion
The State agency may have improperly claimed an estimated $454.9 million in Federal reimbursement through its Medicaid school-based program.
Audit Scope
Scope: $505,513,513 in Federal Medicaid payments for school-based services claimed for reimbursement in Wisconsin from July 1, 2018, through June 30, 2022 (school years 2019 through 2022).
Key Findings Summary
The State agency did not support that all moments coded as Medicaid-eligible were for Medicaid-eligible health services or Medicaid administrative activities.
The State agency did not provide documentation to support ratios used to allocate costs.
The State agency did not sample moments during the beginning of the school year.
AI-Assisted
AI Scope Summary
This audit evaluated Wisconsin DHS's School-Based Services and Medicaid Administrative Claiming costs claimed for Federal Medicaid reimbursement for school years 2019–2022, focusing on RMTS coding accuracy, licensure verification, and IEP ratio-based cost allocation, and concluded that unallowable reimbursements may have been claimed totaling hundreds of millions of dollars, prompting six recommendations and plans to revise methodologies and sampling to ensure compliance in future audits.
AI-Generated Insight
This audit highlights vulnerabilities in RMTS-based cost allocation, including missing student-identifying information, incomplete licensure verification, and privacy constraints around IEP data. The findings underscore the need for verifiable documentation and CMS-approved methodological improvements (SPA, RMTS implementation) to ensure future claims are eligible for Federal reimbursement and auditable.
Audit Objectives
To determine whether the Wisconsin Department of Health Services properly claimed Federal reimbursement through its Medicaid school-based program.
Audit Findings (3)
The State agency did not support that all moments coded as Medicaid-eligible were for Medicaid-eligible health services or Medicaid administrative activities.
The State agency did not provide documentation to support ratios used to allocate costs.
The State agency did not sample moments during the beginning of the school year.
Recommendations (6)
Refund the estimated $67,042,719 to the Federal Government related to moments that could not be supported as Medicaid-eligible health services or Medicaid administrative activities.
Provide documentation that can reasonably support its allocation of health services costs to Medicaid or refund $387,870,393 to the Federal Government.
Ensure that its contractor obtains sufficient information so that the Wisconsin Department of Health Services can validate the contractor’s coding of RMTS moments.
Ensure that school districts verify and document that providers are appropriately licensed or under the direction of licensed providers before they provide health services to students.
Develop an accurate, supportable method to identify Medicaid costs that can be verified with source documents.
Revise its RMTSs to include the beginning of the school year.