Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments
Learn how the AI-generated research projects were createdOverall Conclusion
The audit concludes that without federal action, states will continue to pay millions of dollars in duplicate Medicaid payments; stronger data sharing and real-time enrollment data are needed; Do Not Pay and improved PARIS controls could reduce improper payments.
Source Document
Audit Scope
Audit covers concurrent capitation payments made to Oregon’s Coordinated Care Organizations (CCOs) and Washington managed care entities from January 1, 2019, to December 31, 2022, focusing on identifying Medicaid recipients enrolled in multiple states concurrently. The audit collaborated with HHS-OIG and the Washington State Auditor; included testing of a joint Oregon-Washington sample; analyzed PARIS data quality and timeliness; evaluated the Do Not Pay program; and assessed internal controls of the Office of Payment Accuracy and Recovery (OPAR) and related agencies.
Key Findings Summary
Federal action is needed to help states identify Medicaid concurrent enrollment. Oregon potentially spent $29 million on improper Medicaid benefits for recipients residing in Washington from 2019 to 2022.
States with the largest concurrent enrollment with Oregon were California and Washington, at $134 million and $65 million respectively; some payments are appropriate if recipients were living in Oregon, but payments for those living outside Oregon would be improper.
Oregon paid about $445 million for Medicaid recipients enrolled in Oregon and one or more other states at the same time from 2019 to 2022, a large portion of which were improper.
View the Findings tab to see all 9 findings
AI-Assisted
AI Scope Summary
Assess whether the Oregon Health Authority can improve identification of Medicaid recipients receiving benefits in multiple states concurrently and identify opportunities for reducing duplicate capitation payments through state and federal data sharing and process improvements.
AI-Generated Insight
This audit highlights significant gaps in inter-state visibility of Medicaid enrollment data and the resulting financial waste from concurrent enrollment. It shows how federal data-sharing (PARIS timing, CMS access) and tools like Do Not Pay can curb improper payments, but federal action is essential for real-time data access and proactive prevention.
Audit Objectives
The objective of this audit was to determine if opportunities exist at OHA to improve identification of Medicaid managed care recipients receiving benefits in multiple states concurrently.
Audit Findings (9)
Federal action is needed to help states identify Medicaid concurrent enrollment. Oregon potentially spent $29 million on improper Medicaid benefits for recipients residing in Washington from 2019 to 2022.
States with the largest concurrent enrollment with Oregon were California and Washington, at $134 million and $65 million respectively; some payments are appropriate if recipients were living in Oregon, but payments for those living outside Oregon would be improper.
Oregon paid about $445 million for Medicaid recipients enrolled in Oregon and one or more other states at the same time from 2019 to 2022, a large portion of which were improper.
Do Not Pay program has saved Oregon significant amounts and could help reduce improper payments if scaled; Oregon saved over $11 million in payments and recovered about $4 million, with ROI of $126 returned for every $1 spent.
HHS-OIG testing found 49% of months tested for Washington recipients were improper (490 of 997 months).
Approximately 3% of Oregon’s Medicaid recipients were also enrolled in another state.
PARIS data matching is not timely and has data quality issues; CMS does not provide timely current enrollment data to states; Do Not Pay could bridge gaps.
There are inherent challenges in residency determination for unhoused individuals and frequent movers, increasing risk of duplicate enrollment.
For testing involving six other states, 417 months across 30 recipients showed an average improper months rate of 30%.
Recommendations (7)
Provide matched enrollment data identifying Medicaid beneficiaries concurrently enrolled in two or more states (Do Not Pay Center).
Identify internal controls addressing risks around concurrent enrollment for unhoused recipients or children in multiple households.
Submit a budget request for 4 FTE, triage PARIS, Do Not Pay pilot, etc.
Implement a process by 2026 to recoupuplicate enrollment payments from CCOs for recipients who live out of state (target date Mar 31, 2026).
Submit a budget request for 4 additional FTE for the Data Matching Unit (DMU) for approval and funding (target date Dec 31, 2027).
Develop a process to triage PARIS matches within the Data Matching Unit (target date Jun 30, 2025).
Work with US Treasury’s Do Not Pay Business Center on a joint WA/OR pilot project for concurrent enrollment (target date Dec 31, 2025).