Evidence record
Without Federal Action, States Will Continue to Pay Millions of Dollars in Duplicate Medicaid Payments
- Jurisdiction
- Oregon
- Publishing agency
- Oregon Secretary of State, Audits Division
- Publication date
- October 18, 2024
- Source record
- Original document linked
Findings
9
Recommendations
7
Overall conclusion
The audit concludes that without federal action, states will continue to pay millions of dollars in duplicate Medicaid payments; stronger data sharing and real-time enrollment data are needed; Do Not Pay and improved PARIS controls could reduce improper payments.
Scope
Audit covers concurrent capitation payments made to Oregon’s Coordinated Care Organizations (CCOs) and Washington managed care entities from January 1, 2019, to December 31, 2022, focusing on identifying Medicaid recipients enrolled in multiple states concurrently. The audit collaborated with HHS-OIG and the Washington State Auditor; included testing of a joint Oregon-Washington sample; analyzed PARIS data quality and timeliness; evaluated the Do Not Pay program; and assessed internal controls of the Office of Payment Accuracy and Recovery (OPAR) and related agencies.
Findings (9)
Each finding has a stable link.
- F-767
Federal action is needed to help states identify Medicaid concurrent enrollment. Oregon potentially spent $29 million on improper Medicaid benefits for recipients residing in Washington from 2019 to 2022.
- F-768
States with the largest concurrent enrollment with Oregon were California and Washington, at $134 million and $65 million respectively; some payments are appropriate if recipients were living in Oregon, but payments for those living outside Oregon would be improper.
- F-769
Oregon paid about $445 million for Medicaid recipients enrolled in Oregon and one or more other states at the same time from 2019 to 2022, a large portion of which were improper.
- F-775
Do Not Pay program has saved Oregon significant amounts and could help reduce improper payments if scaled; Oregon saved over $11 million in payments and recovered about $4 million, with ROI of $126 returned for every $1 spent.
- F-770
HHS-OIG testing found 49% of months tested for Washington recipients were improper (490 of 997 months).
- F-771
Approximately 3% of Oregon’s Medicaid recipients were also enrolled in another state.
- F-772
PARIS data matching is not timely and has data quality issues; CMS does not provide timely current enrollment data to states; Do Not Pay could bridge gaps.
- F-773
There are inherent challenges in residency determination for unhoused individuals and frequent movers, increasing risk of duplicate enrollment.
- F-774
For testing involving six other states, 417 months across 30 recipients showed an average improper months rate of 30%.
Recommendations (7)
- R-679
Provide matched enrollment data identifying Medicaid beneficiaries concurrently enrolled in two or more states (Do Not Pay Center).
Related finding F-772 - R-680
Identify internal controls addressing risks around concurrent enrollment for unhoused recipients or children in multiple households.
Related finding F-773 - R-681
Submit a budget request for 4 FTE, triage PARIS, Do Not Pay pilot, etc.
Related finding F-772 - R-678
Implement a process by 2026 to recoupuplicate enrollment payments from CCOs for recipients who live out of state (target date Mar 31, 2026).
Related finding F-769 - R-675
Submit a budget request for 4 additional FTE for the Data Matching Unit (DMU) for approval and funding (target date Dec 31, 2027).
Related finding F-772 - R-676
Develop a process to triage PARIS matches within the Data Matching Unit (target date Jun 30, 2025).
Related finding F-772 - R-677
Work with US Treasury’s Do Not Pay Business Center on a joint WA/OR pilot project for concurrent enrollment (target date Dec 31, 2025).
Related finding F-775