Evidence record
Timely Notification of Inpatient Hospital Stays Could Help Reduce Improper Medicaid Payments
- Jurisdiction
- Oregon
- Publishing agency
- Oregon Secretary of State, Audits Division
- Publication date
- December 8, 2021
- Source record
- Original document linked
Findings
5
Recommendations
2
Overall conclusion
OHA lacks timely notification of inpatient hospital stays, which results in some claims being paid for services not provided because the Medicaid client was in the hospital; there is significant improper payments and high-risk claims related to in-home services, NEMT, and private duty nursing during inpatient stays; improvement through notifications and controls is needed.
Scope
Paid Medicaid claims from January 2017 to February 2020 for recipients who experienced extended in-patient hospital stays. The scope did not include Medicaid claims during the COVID-19 pandemic.
Findings (5)
Each finding has a stable link.
- F-855
Testing identified $52,344 in improper payments to providers not associated with the hospital who likely did not provide services, and approximately $1.6 million in additional payments identified as high risk of being improper.
- F-856
In-home services are not allowable during inpatient hospital stays; testing found $49,875 in improper payments across 42 claims, and we estimate approximately $1.3 million in other in-home service claims that are at high risk of being improper.
- F-857
Non-emergency medical transportation (NEMT) had $1,644 in improper payments across 73 claims, with about $211,507 in other NEMT claims at a high risk of being improper.
- F-858
Private duty nursing: $825 in improper payments across three claims, with about $5,982 in other private duty nursing claims at a high risk of being improper.
- F-854
OHA lacks timely notification of inpatient hospital stays, leading to payments for services not provided while a Medicaid client is in the hospital.
Recommendations (2)
- R-756
Reimburse the federal government for the federal portion of the identified improper payment amount.
Related finding F-855 - R-757
Develop and implement cost-effective controls that would prevent or detect improper payments for unallowable services while a Medicaid client is inpatient, including timely notification of hospital admissions integrated into claims processing.
Related finding F-854