Tennessee Claimed Federal Medicaid Reimbursement for Millions of Dollars in Targeted Case Management Services That Did Not Comply With Federal and State Requirements
Learn how the AI-generated research projects were createdOverall Conclusion
The OIG concluded that Tennessee claimed Federal Medicaid reimbursement for a subset of TCM services during FYs 2021–2023 that did not comply with Federal and State requirements, due to failure to verify eligibility for the designated target group and to assess TEIS cases properly. The estimated Federal overpayment totaled at least $59.3 million, and the report recommends refunds and procedural revisions. Tennessee did not concur with the recommendations.
Audit Scope
FYs 2021 through 2023 (audit period); October 1, 2020, through September 30, 2023; sampling frame of 682,914 grouped line items totaling $503,468,529; 150 grouped line items sampled; 120 by Department of Children's Services (DCS) case managers and 30 by Department of Intellectual and Developmental Disabilities (DIDD) case managers; Tennessee claimed reimbursement only for the 'Children in State Custody or at Risk of State Custody' target group.
Key Findings Summary
Of 150 sampled grouped line items, 43 were unallowable because enrollees did not meet the eligibility criteria for the target group designated in the Tennessee State plan.
Thirteen sampled grouped line items involved enrollees who were served by DCS case managers but who were not at serious or imminent risk of entering State custody, thus not meeting eligibility criteria.
Thirty sampled grouped line items involved enrollees who had received TEIS early intervention case management services, but the State did not perform an assessment to determine whether these enrollees were at serious or imminent risk of entering State custody, leading to incorrect TCM claims for Federal reimbursement.
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AI-Assisted
AI-Generated Insight
This audit highlights the critical need for rigorous validation of target-group eligibility before Medicaid reimbursements for targeted case management. Reliance on certain assessment tools and inconsistent TEIS practices contributed to unallowable claims, pointing to a broader risk across states for misclassification of eligibility and the importance of aligning state processes with CMS requirements.
Audit Objectives
Our objective was to determine whether the State agency claimed Federal Medicaid reimbursement for TCM services during FYs 2021 through 2023 in accordance with Federal and State requirements.
Audit Findings (4)
Of 150 sampled grouped line items, 43 were unallowable because enrollees did not meet the eligibility criteria for the target group designated in the Tennessee State plan.
Thirteen sampled grouped line items involved enrollees who were served by DCS case managers but who were not at serious or imminent risk of entering State custody, thus not meeting eligibility criteria.
Thirty sampled grouped line items involved enrollees who had received TEIS early intervention case management services, but the State did not perform an assessment to determine whether these enrollees were at serious or imminent risk of entering State custody, leading to incorrect TCM claims for Federal reimbursement.
Based on the sample results, the OIG estimated that Tennessee claimed at least $59.3 million (Federal share) in unallowable Medicaid reimbursement.
Recommendations (2)
Refund $59,300,776 (Federal share) in overpayments to the Federal Government.
Revise procedures to include a step to verify that enrollees meet the eligibility criteria for an approved target group before submitting claims for Federal Medicaid reimbursement as TCM claims.