Performance Audit of Medicaid Managed Care Organizations for Fiscal Year 2016

HFS made multiple monthly capitation payments for the same months for the same individuals, totaling $590,237.

HFS made $7.11 billion in capitation payments, with an additional $7.61 billion paid via fee-for-service.

HIF and gross-up payments totaled $137,938,567.

HFS did not maintain complete and accurate information needed to monitor payments made to and by the 12 MCOs during FY16.

HFS could not provide all paid claims, denied claims, administrative costs, coordinated care costs, or MLR calculations since 2012.

Encounter data was incomplete and not used to set 2016 capitation rates.

Duplicative capitation payments were identified for 302 individuals.

HFS did not perform on-site reviews or verify the accuracy of reported payment data.

HFS did not monitor or track encounter data or expenditures for DASA, LTC, waiver services, and MMAI.

HFS could not provide valid data on denied claims.

Monitor actual administrative costs to ensure they do not exceed contractual limits.

Calculate and review Medical Loss Ratios for 2013-2016 to identify overpayments.

Require all MCOs to submit complete Medicaid provider payment data and perform on-site reviews.

Provide clear guidance for reporting denied claims and ensure they are submitted.

Identify and remove duplicate recipients from eligibility data and recoup overpayments.

Monitor compliance with contractual provisions for new MCO contracts.