Evidence record
West Virginia Medicaid Managed-Care Rebates Associated With Physician-Administered Drugs
- Jurisdiction
- West Virginia
- Audit organization
- Office of Inspector General, U.S. Department of Health and Human Services
- Publication date
- February 2026
- Source record
- Original document linked
Findings
3
Recommendations
2
Overall conclusion
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). Internal controls did not consistently ensure data were used to invoice rebates. The WV Bureau for Medical Services took corrective actions, including system changes and re-processing of claims for rebate invoicing in 2025, but the OIG maintained its recommendations and will consider them implemented when the funds are refunded.
Scope
Audit period January 1, 2019 through December 31, 2022; reviewed physician-administered drug claims paid by West Virginia Medicaid Bureau for Medical Services’ managed-care organizations; used CMS top-20 multiple-source drug lists, CMS Medicaid Drug Rebate File, and Medicaid Drug Product File to classify drugs as single-source or top-20 multiple-source; evaluated data collection and invoicing processes.
Findings (3)
Each finding has a stable link.
- F-1215
The State agency did not invoice for, and collect from manufacturers, estimated rebates totaling $8.2 million ($6.1 million Federal share) for physician-administered drugs dispensed to MCO enrollees.
- F-1216
Although the State agency’s policies required the collection of drug utilization data necessary to invoice for rebates on all physician-administered drug claims, the State agency’s internal controls did not always ensure that the collected data were used to invoice manufacturers and collect rebates for physician-administered drugs dispensed to MCO enrollees.
- F-1217
In 2019, the State agency’s fiscal agent updated its rebate administration system; however, during the audit period the State agency did not receive all of the necessary information to invoice and collect rebates from the drug manufacturers.
Recommendations (2)
- R-1079
Refund to the Federal Government $6,055,786 (Federal share) for claims for single-source physician-administered drugs that were ineligible for Federal reimbursement.
Related finding F-1215 - R-1080
Refund to the Federal Government $22,718 (Federal share) for claims for top-20 multiple-source physician-administered drugs that were ineligible for Federal reimbursement.
Related finding F-1215