Evidence record
Improper Capitation Payments
- Jurisdiction
- Ohio
- Publishing agency
- Ohio Auditor of State
- Audit organization
- Auditor of State of Ohio
- Publication date
- December 28, 2021
- Source record
- Original document linked
Findings
7
Recommendations
5
Overall conclusion
The Department has processes to identify and recoup improper capitation payments, but controls are not sufficiently robust to ensure all improper payments are identified and recouped. The audit identified over $118.5 million in improper capitation payments not recouped for SFYs 2018-2020, with substantial amounts involving duplicates, incarcerated, and deceased individuals. The Department has implemented improvements, including automation, dashboards, and robotic process automation, since 2019-2021, but further actions are required to fully recoup payments and prevent future errors.
Scope
SFYs 2018-2020 (July 1, 2017 through June 30, 2020). Focus on capitation payments to managed care organizations for Medicaid recipients, specifically duplicate payments due to multiple IDs, payments during incarceration, and payments after death; cross-matching data from Medicaid, ODRC, and ODH; analysis used Medicaid database and MITS; results include primary and secondary matches and recommendations for recoupment.
Findings (7)
Each finding has a stable link.
- F-1193
Identified over $118.5 million in improper capitation payments that had not been recouped by the Department in SFYs 2018-2020.
- F-1194
Duplicate capitation payments: 61,852 capitation payments totaling $29,175,678 were made on behalf of recipients with the same SSN; approximately $14.5 million not recouped.
- F-1195
Additional potential duplicate matches: 15,597 matches totaling about $134,906,167; potential savings up to $67.5 million.
- F-1196
Incarcerated payments: 29,412 recipients and 160,850 capitation payments totaling $100,663,282 not recouped; 1,281 potential matches with over $4 million in additional payments.
- F-1197
Deceased payments: 3,560 capitation payments totaling $3,383,680 not recouped; 904 potential matches with about $12.6 million in additional payments.
- F-1198
Data validity issues: missing first/last names, DOBs, and over 80,000 recipients with invalid SSNs (000-00-0000 or 999-99-9999).
- F-1199
Fee-for-service payments analysis identified over $8 million in potential improper payments during managed care enrollment; requires further analysis.
Recommendations (5)
- R-1066
Recover the approximately $14.5 million in duplicate capitation payments, $100,663,282 in capitation payments for incarcerated individuals and $3,383,680 in capitation payments for deceased individuals from the managed care organizations (MCOs) and refund the federal share.
Related finding F-1193 - R-1067
Review potential improper capitation payments for each objective and identify and recoup all improper capitation payments.
Related finding F-1193 - R-1068
Evaluate current processes for identifying duplicate recipient IDs, incarcerated individuals and deceased individuals and updating recipient data files in a timely manner.
Related finding F-1194 - R-1069
Assess the steps taken to recoup all appropriate capitation payments when a change occurs that impacts eligibility, such as incarceration or when a duplicate payment is identified.
Related finding F-1196 - R-1070
Correct or enhance system controls to prevent future erroneous capitation payments and improve accuracy of data on participation in the Medicaid program.
Related finding F-1198