Maryland Department of Health Medical Care Programs Administration Audit Report

MCPA did not have effective processes to identify, prevent, and recover questionable Medicaid payments, including $7.1 million in payments on behalf of incarcerated and deceased recipients.

MCPA did not adequately monitor the hospital claims audit contractor and had not collected or recovered improper claims identified by the contractor totaling $6.9 million.

The Medical Care Programs Administration (MCPA) did not ensure that all referrals of potential third-party health insurance information were investigated and recorded in the Medicaid Management Information System (MMIS II), which could result in MCPA improperly paying claims that should have been paid by a third party.

MCPA did not ensure that changes to recipient Medicaid eligibility information were processed timely and accurately.

MCPA had not established adequate oversight to ensure that all Community First Choice program recipients received personal assistance services in accordance with their plans of service.

MCPA did not monitor the utilization control agent contractor to ensure continued stay reviews of Medicaid recipients receiving services from nursing facilities were performed timely.

MCPA did not have an established process to ensure costly recipient ventilator care claims submitted by nursing facilities were valid, as required by State regulations.

MCPA did not conduct the required audits of Medical Day Care and Supports Planning providers, and the related audit policy and procedures were not sufficiently comprehensive.

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Monitor the Utilization Control Agent (UCA) contractor to ensure continued stay reviews are performed timely and assess any applicable liquidated damages.

Establish procedures to periodically validate ventilator care claims submitted by nursing facilities and recoup any unsupported or improper payments.

Audit Medical Day Care (MDC) providers in accordance with policy and test all MDC provider claims since the preceding audit.

Enhance the MDC audit policy to define scope and testing methodology and require expanded testing when significant deficiencies are identified.

Adequately monitor the hospital claims audit contractor and obtain all deliverables required by the contract.

Pursue recovery of overpaid hospital claims identified by the audit contractor in a timely manner.

Interface all third-party health insurance information provided by the third-party liability vendor with MMIS II.

Record all MCO insurance referrals in MMIS II in a timely manner.

Implement a monthly review of missing Social Security Numbers (SSNs) and refer cases to the Department of Human Services (DHS) and Local Health Departments (LHDs) for investigation.

Develop and implement a standalone platform or process to document investigations of questionable recipient eligibility to support timely corrective actions.

Establish a process to identify, prevent, and recover improper fee-for-service payments related to incarcerated recipients.

Document efforts to identify and remove deceased recipients from Medicaid and pursue recovery of improper payments after the recipients’ dates of death.

Ensure that recipient eligibility information is updated timely and accurately in MMIS II, and correct errors identified during supervisory reviews.

Establish a process to monitor Community First Choice (CFC) nurse monitoring and ensure all recipients are monitored; address long-standing non-compliance at Local Health Departments.