Medicaid Residency
Learn how the AI-generated research projects were createdOverall Conclusion
Overall, the audit concludes that the Louisiana Department of Health should improve its processes for identifying and removing Medicaid beneficiaries who no longer reside in Louisiana, as substantial PMPM payments were made to out-of-state-residing beneficiaries and related out-of-state service payments.
Source Document
Audit Scope
Scope: This performance audit covers the Louisiana Department of Health’s administration of Louisiana’s Medicaid program from July 1, 2016 through March 31, 2023, focusing on the policies, procedures, and data sources used to identify and remove beneficiaries who no longer reside in Louisiana and no longer qualify for Medicaid. The audit examines the processes used to verify residency (including self-attestation, address updates, PARIS matches, and data from the Louisiana Office of Motor Vehicles), the use of data sources such as PARIS, OMV, and CMS NPI data, and the interaction with managed care entities (MCEs) under LDH’s full-risk PMPM model. The report also evaluates CMS PHE unwind guidance and constraints that limited termination actions during the Public Health Emergency. It encompasses payments to MCEs and out-of-state providers identified in the beneficiary eligibility and service data, with a period review from July 2016 through February 2023 (and up to March 31, 2023 for the scope of data).
Key Findings Summary
LDH should improve its process for identifying Medicaid beneficiaries who no longer reside in Louisiana and therefore no longer qualify for Louisiana’s Medicaid program; the audit identified that LDH paid approximately $112.6 million in per‑member per‑month (PMPM) payments to MCEs for 13,771 adult beneficiaries who did not appear to have resided in Louisiana…
Approximately $3.0 million in PMPMs were paid for 380 beneficiaries identified as residing out-of-state after LDH’s eligibility system listed them with out‑of‑state addresses, and MCEs paid $92,087 to out-of-state service providers after the beneficiaries were identified as living out-of-state.
Approximately $109.5 million in PMPMs were paid for 13,391 beneficiaries who, according to Louisiana OMV data, obtained a driver’s license in another state; MCEs paid about $2.8 million to out-of-state providers after beneficiaries obtained out-of-state licenses.
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AI-Assisted
AI Scope Summary
Assess and improve LDH’s processes for identifying and removing Medicaid beneficiaries who no longer reside in Louisiana and are ineligible, using multiple data sources (eligibility records, PARIS, OMV, NPI) and considering policy constraints during the PHE unwind.
AI-Generated Insight
This audit highlights the critical role of cross‑agency data sharing and data analytics in preventing improper Medicaid payments. By analyzing eligibility records, PARIS matches, OMV driver’s license data, and provider NPI data, the report shows that residency verification gaps during the COVID-19 PHE unwind led to significant PMPM expenditures and out-of-state service payments. The findings underscore the need for proactive front‑end data checks and integration of external data sources to accurately identify beneficiaries who no longer reside in Louisiana and to reduce improper payments, while balancing CMS guidelines during emergency periods.
Audit Objectives
To analyze processes used by LDH to identify and remove Medicaid beneficiaries who no longer reside in Louisiana and no longer qualify for Louisiana’s Medicaid program.
Audit Findings (7)
LDH should improve its process for identifying Medicaid beneficiaries who no longer reside in Louisiana and therefore no longer qualify for Louisiana’s Medicaid program; the audit identified that LDH paid approximately $112.6 million in per‑member per‑month (PMPM) payments to MCEs for 13,771 adult beneficiaries who did not appear to have resided in Louisiana during the coverage period paid for by these PMPMs.
Approximately $3.0 million in PMPMs were paid for 380 beneficiaries identified as residing out-of-state after LDH’s eligibility system listed them with out‑of‑state addresses, and MCEs paid $92,087 to out-of-state service providers after the beneficiaries were identified as living out-of-state.
Approximately $109.5 million in PMPMs were paid for 13,391 beneficiaries who, according to Louisiana OMV data, obtained a driver’s license in another state; MCEs paid about $2.8 million to out-of-state providers after beneficiaries obtained out-of-state licenses.
LDH did not always terminate or remove beneficiaries whose PARIS data indicated out-of-state residency; CMS/LDH procedures allowed termination only under certain conditions during the PHE, but there were 68 PARIS matches (July 2020–January 2023) where LDH did not consistently contact other states or beneficiaries to determine residency, resulting in $328,392 in PMPMs for these beneficiaries after being listed as out‑of‑state.
An additional 3,633 beneficiaries enrolled in Louisiana’s Medicaid program from May 2017 through February 2023 who only received services from out-of-state providers, despite not having an out-of-state address in LDH’s system nor an out-of-state driver’s license.
In several cases, beneficiaries had out-of-state addresses listed and continued to receive PMPMs even though they had not used Louisiana-based services; examples include Texas and Mississippi addresses with months of PMPMs and no Louisiana services.
LDH could strengthen processes by incorporating OMV data, CMS NPI data, and Medicaid data to flag beneficiaries who may no longer reside in Louisiana and only receive out‑of‑state services.
Recommendations (4)
Ensure that beneficiaries identified as residing out-of-state in LDH’s eligibility systems and who no longer qualify for Louisiana Medicaid are removed from the program.
Review and strengthen procedures for handling PARIS matches and ensure timely action on PARIS results.
Incorporate Louisiana OMV data into eligibility determinations to identify beneficiaries who may no longer live in Louisiana.
Incorporate CMS NPI data and Medicaid claims/encounter data to identify beneficiaries who potentially live out-of-state (noting management’s stance on this recommendation).