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
Tennessee claimed Federal Medicaid reimbursement for some TCM services during the audit period that did not comply with Federal and State requirements.
Source Document
Audit Scope
FY 2021 through 2023; 150 grouped line items sampled; Tennessee's claims for Targeted Case Management (TCM) services under Federal Medicaid reimbursement, with attention to eligibility criteria and the state plan.
Key Findings Summary
Of 150 sampled grouped line items, 43 were unallowable because the enrollees did not meet the eligibility criteria for the target group designated in the Tennessee State plan.
Of these, 13 sampled grouped line items involved enrollees who were not at serious or imminent risk of entering State custody and therefore did not meet the eligibility criteria.
The remaining 30 sampled grouped line items involved enrollees who had received early intervention case management services. Because Tennessee did not perform an assessment to determine whether these enrollees were at serious or imminent risk of entering State custody, the State incorrectly claimed those services as TCM services for Federal Medicaid reimburs…
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AI-Assisted
AI Scope Summary
The audit aimed to determine if Tennessee claimed Federal Medicaid reimbursement for Targeted Case Management (TCM) services during FY 2021–2023 in accordance with Federal and State requirements, focusing on the eligibility criteria for the designated target group and proper classification of services. It found unallowable claims totaling at least $59.3 million (Federal share) and recommended refunds and procedural changes to verify eligibility before billing.
AI-Generated Insight
The audit identifies improper Targeted Case Management (TCM) claims due to insufficient eligibility verification, indicating a need for stronger controls to ensure only eligible TCM services are billed to Federal Medicaid and for recovering improper payments.
Audit Objectives
Determine whether Tennessee claimed Federal Medicaid reimbursement for Targeted Case Management (TCM) services during fiscal years 2021 through 2023 in accordance with Federal and State requirements.
Audit Findings (4)
Of 150 sampled grouped line items, 43 were unallowable because the enrollees did not meet the eligibility criteria for the target group designated in the Tennessee State plan.
Of these, 13 sampled grouped line items involved enrollees who were not at serious or imminent risk of entering State custody and therefore did not meet the eligibility criteria.
The remaining 30 sampled grouped line items involved enrollees who had received early intervention case management services. Because Tennessee did not perform an assessment to determine whether these enrollees were at serious or imminent risk of entering State custody, the State incorrectly claimed those services as TCM services for Federal Medicaid reimbursement.
Based on our sample results, we estimated that Tennessee claimed at least $59.3 million (Federal share) in unallowable Medicaid reimbursement.
Recommendations (2)
Refund $59,300,776 (Federal share) in unallowable Medicaid reimbursement to the Federal Government.
Revise its procedures to include a step to verify that enrollees meet the eligibility criteria for an approved target group before it submits claims for Federal Medicaid reimbursement as TCM claims.