Evidence record
Pennsylvania Capitation Payments for Enrollees With Multiple Medicaid Identification Numbers
- Jurisdiction
- Pennsylvania
- Publication date
- July 2025
- Source record
- Original document linked
Findings
3
Recommendations
5
Overall conclusion
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 by insufficient controls to detect or prevent duplicate Medicaid IDs, and the state agency’s match-scoring algorithm and related processes did not reliably prevent multiple IDs from being assigned. Five recommendations were issued to refund the Federal share and to improve monitoring, data quality, and safeguards.
Scope
Audit covered Medicaid capitation payments made by the Pennsylvania Department of Human Services to Managed Care Organizations (MCOs) from January 1, 2019 through December 31, 2022, focusing on 3,584 enrollee-matches where an individual had more than one Medicaid ID number. The detailed sampling involved a stratified random sample of 100 enrollee-matches from a frame comprising 32,867 individual capitation payments totaling $19,846,784 ($10,390,232 Federal share). The audit did not review the State agency’s entire internal control structure beyond controls related to preventing or detecting duplicate IDs; the objective was to determine if unallowable capitation payments were made as a result of multiple IDs and to estimate the total and Federal share of such overpayments.
Findings (3)
Each finding has a stable link.
- F-352
In a sample of 100 enrollee-matches, 2 enrollee-matches were paid correctly, while 98 enrollee-matches resulted in unallowable capitation payments totaling $1,068,308 ($559,087 Federal share).
- F-354
Based on the sample results, the State agency made unallowable capitation payments totaling at least $8,784,549 ($4,596,390 Federal share) during the audit period.
- F-353
The unallowable payments occurred because the State agency’s controls were insufficient to detect or prevent multiple Medicaid ID numbers from being assigned to the same enrollee.
Recommendations (5)
- R-315
Refund to the Federal Government $4,596,390 in unallowable payments.
Related finding F-354 - R-316
Review capitation payments subsequent to the audit period and refund any unallowable payments.
Related finding F-354 - R-317
Use the Zero SSN report consistently and update it monthly, in accordance with the State agency’s policy and procedures, to prevent the issuance of multiple Medicaid ID numbers for the same enrollee.
Related finding F-353 - R-318
Test the match-scoring algorithm to ensure it is working as intended.
Related finding F-353 - R-319
Enhance or establish new controls to prevent, detect, and correct instances where multiple Medicaid ID numbers are assigned to the same enrollee.
Related finding F-353