The Office of Inspector General found that West Virginia did not invoice manufacturers for some rebates due on physician-administered drugs dispensed to enrollees of Medicaid managed-care organizations during the audit period, totaling $8.2 million ($6.1 million Federal share)…
Although the State agency improved its controls over invoicing for rebates for physician-administered drugs, during our audit period the State agency did not comply with Federal Medicaid requirements for invoicing manufacturers for rebates for some physician-administered and p…
For our audit period, the Maine Department of Health and Human Services’s FFS Medicaid payments for rehabilitative and community support services provided to children diagnosed with autism included improper and potentially improper payments. Improper payments totaled at least…
The audit determined that Illinois made unallowable managed care capitation payments for incarcerated enrollees during the audit period, totaling at least $9.5 million with $8.3 million Federal share, and identified failures to terminate enrollment as required. Recovered findi…
We estimate that Medicaid agencies made $207,501,380 ($138,645,710 Federal share) in unallowable capitation payments to MCOs for deceased enrollees during the audit period (July 1, 2021 – June 30, 2022).
Timely followup care after pediatric suicidal thoughts or behaviors is not consistently achieved across states; about half of cases did not have a followup visit within 7 days and 21 percent had none within 60 days; shortages of behavioral health providers and difficulties con…
New Jersey did not ensure that the State agency adequately monitored and ensured compliance by its MCOs and fiscal intermediary with Federal and State requirements for PPP PCA services; as a result, the program was vulnerable to misuse of Federal funds and the health and safet…
The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for FYs 2021 through 2023. The audit identified underreporting across multiple categories, with 12 cases reported and returned (totaling $290,584) compared with…
The data brief concludes that there is no clear, positive correlation between higher direct care compensation and higher nursing hours per resident day (HPRD). Increases in direct care compensation are largely attributed to higher labor costs from contracting for nursing staff…
The Wisconsin Department of Health Services’ ForwardHealth program did not provide adequate oversight of FFS Medicaid ABA payments, resulting in improper and potentially improper payments for autism-related ABA services. The program had not conducted a statewide postpayment re…
The OIG concluded that Pennsylvania made unallowable capitation payments totaling at least $8,784,549 ($4,596,390 Federal share) for enrollees with multiple Medicaid ID numbers during the audit period (January 1, 2019 – December 31, 2022). The unallowable payments were caused…
The Maryland Department of Health did not fully comply with Federal waiver and State requirements in overseeing adult day care facilities; 253 noncompliance instances were identified across health and safety and administrative areas, with inspections insufficient to detect vio…
The Ohio Department of Medicaid did not fully comply with Federal waiver and State requirements in overseeing providers serving adults in the ADS program; inspections were insufficient to ensure a continuously safe and nonhazardous environment, placing adults at risk.
Overall, the audit determined that North Carolina's Medicaid control environment, risk management practices, and governing processes operate at a moderate risk level, with three risk areas rated high and three rated moderate; the State agency has implemented numerous controls…
The State agency did not fully comply with Federal waiver and State requirements in overseeing DAHS facilities serving people with special health care needs, and its inspections were not sufficient to ensure a safe and nonhazardous environment, leaving program participants at…
The audit found that Colorado made unallowable capitation payments to Medicaid managed care organizations for deceased enrollees, resulting in significant financial losses and reporting inaccuracies. The State agency lacked adequate controls and policies to prevent and recover…
Twelve of the thirteen selected States did not accurately calculate the Federal share of Medicaid collections subject to the increased COVID-19 FMAP, resulting in net underreporting of $61.8 million. CMS concurred with all four recommendations and described actions to address…
We estimated that the State agency incurred costs of approximately $19.9 million ($15.5 million Federal share) for August 2021 capitation payments made on behalf of enrollees who were residing and concurrently enrolled for Medicaid in another State. This amount represents pote…
The State agency did not report and return the Federal share of all MFCU-determined Medicaid overpayments identified for the period under review (October 1, 2019 through September 30, 2021).
California improperly claimed Federal Medicaid reimbursement for capitation payments to noncitizens with UIS by applying an outdated proxy percentage that did not reflect the true costs of nonemergency services; recommends refund and coordination with CMS to determine reimburs…
Colorado did not report and refund the correct Federal share of Medicaid overpayments identified by its Program Integrity Section during Oct 1, 2014 through Dec 31, 2020; 80 of 403 cases contained unreported or incorrectly reported amounts, with late reporting and misused feed…
CMS did not ensure that selected States complied with Medicaid managed care MH/SUD parity requirements; noncompliance was widespread across eight States, including missing parity provisions in contracts, lack of parity analyses and public posting, and restrictive practices by…
Colorado could better ensure that nursing homes participating in Medicare and Medicaid comply with Federal life safety, emergency preparedness, and infection control requirements. Deficiencies were observed across all 20 nursing homes audited, indicating ongoing oversight chal…
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 p…