Evidence record
Multiple States Made Medicaid Capitation Payments to Managed Care Organizations After Enrollees’ Deaths
- Jurisdiction
- CaliforniaFloridaGeorgiaIllinoisIndianaKansasMichiganMinnesotaNew YorkNorth CarolinaOhioTennesseeTexasWisconsin
- Publication date
- November 2023
- Source record
- Original document linked
Findings
5
Recommendations
3
Overall conclusion
The report concludes that improper Medicaid capitation payments to MCOs on behalf of deceased enrollees remain a persistent issue across states, with prior unallowable payments totaling about $249 million and ongoing uncollected federal shares. While CMS has made substantial progress implementing prior recommendations and recovering overpayments (about $126 million collected), the OIG identifies additional data-matching and oversight steps—particularly routine matching of T-MSIS enrollment data against SSA’s Death Master File—to further reduce improper payments and strengthen program integrity.
Scope
This performance audit summarizes the results of 14 prior OIG audits that identified unallowable Medicaid capitation payments made by States to managed care organizations (MCOs) on behalf of deceased enrollees, covering audit periods from July 1, 2009, through December 31, 2019, with total unallowable payments of about $248.6 million ($171.8 million Federal share) identified across 14 states. It also reviews CMS actions and potential enhancements to oversight, including a proposed data-matching process between the Transformed MSIS (T-MSIS) enrollment data and SSA’s Death Master File (DMF) to identify high-risk states and verify and recover improper payments. The audit work was conducted December 2020 through June 2023, and CMS comments extend to August 2023. The scope does not assess the overall CMS internal control structure or the Medicaid program beyond audit resolution and program integrity-related controls.
Findings (5)
Each finding has a stable link.
- F-285
In prior audits of 14 states, unallowable Medicaid capitation payments to MCOs on behalf of deceased enrollees totaled approximately $249 million ($172 million Federal share); CMS concurred with all recommendations and actions have been taken on most.
- F-287
The total unallowable capitation payments identified across the 14 states were $248,573,235; Federal share was $171,817,215; $41,003,804 of the Federal share remained uncollected as of the audit period and CMS is working with the states to collect it.
- F-289
CMS has collected about $126 million (Federal share); 38 of 46 prior recommendations implemented; 8 recommendations unimplemented; 3 states associated with remaining unimplemented recommendations.
- F-286
In this audit, CMS could take additional actions to help states continue to make improper capitation payments by developing a process to routinely match Transformed Medicaid Statistical Information System (T-MSIS) enrollment data against the Social Security Administration’s Death Master File (DMF) data to identify high-risk states and provide results to those states for verification and corrective action.
- F-288
Reasons States Made Unallowable Medicaid Capitation Payments: 11 states did not always identify and process death information; 4 states did not use interfaces to automatically identify death dates; 9 states did not enter DODs in MMIS; 6 states had inadequate monthly review procedures; 5 states did not regularly use all available data sources (e.g., Accurint, obituaries) to identify DODs; 3 states did not collaborate with entities providing DOD information to identify inconsistencies.
Recommendations (3)
- R-274
Collect the outstanding unallowable payments totaling the estimated $41,003,804 identified in prior audits.
Related finding F-287 - R-275
Ensure that States complete actions on the remaining recommendations to address identified internal control weaknesses.
Related finding F-289 - R-276
Continue to explore opportunities for using T-MSIS and SSA’s DMF data to improve oversight; develop a process to match enrollment and payment information in T-MSIS with the DMF and provide results of that match to States to reduce Medicaid capitation payments to MCOs for deceased enrollees.
Related finding F-286